Practice guidelines
Searchable ophthalmology diagnosis wiki.
Concise panels built from the resident source PDF and paired with reputable references. Review-of-systems smartphrases are separated from disease guidance.
182diagnosis entries
8review-of-systems prompts
PDF + referencessource-grounded facts
Diagnosis library
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Generic filler has been removed. Diagnosis sections appear only when there are useful source-derived or reference-checked facts for that topic.
ANCA / Vasculitis Review of Systems Review of systems - ROS prompt
Review of systems questions
- Unexplained fever
- Weight loss
- Nasal crusting
- Sinus/facial pain
- Chronic rhinosinusitis
- Nasal obstruction
- Smell disturbance
- Bloody discharge
- Excessive tearing
- Hearing loss
- Cartilaginous changes of the ears or nose
- Chest pain
- Shortness of breath
- Cough
- Hemoptysis
- Hematuria
- Rash.
Bulbar / Myasthenic Symptom Screen Review of systems - ROS prompt
Review of systems questions
- Dysphagia
- Dysphonia
- Difficulty with breathing
- Weakness in proximal muscles
- Diplopia
- Fatigability throughout day
- Autoimmune history.
Flashes, Floaters, Curtain Screen Review of systems - ROS prompt
Review of systems questions
- Symptoms of flashes
- Floaters
- Dark curtain.
Giant Cell Arteritis Neuro-ophthalmology - Patient education + clinical checklist
Age over 50 with new headache, scalp tenderness, jaw claudication, polymyalgia symptoms, fever, weight loss, diplopia, transient dimming, or permanent vision loss.
Key history
- Age over 50 with new headache, scalp tenderness, jaw claudication, polymyalgia symptoms, fever, weight loss, diplopia, transient dimming, or permanent vision loss.
Exam findings
- Assess visual acuity, pupils/APD, color vision, visual fields, temporal artery tenderness/nodularity, optic nerve edema or pallor, and retinal artery occlusion.
Workup
- ESR, CRP, and platelet count support the diagnosis but normal values do not exclude GCA when suspicion is high.
Management
- Suspected visual or systemic GCA requires urgent corticosteroid treatment; do not delay treatment for biopsy or imaging when vision is threatened.
Trusted references
Idiopathic Intracranial Hypertension / Papilledema Neuro-ophthalmology - Patient education + clinical checklist
Ask about headache, transient visual obscurations, pulsatile tinnitus, diplopia, nausea/vomiting, positional symptoms, weight change, pregnancy, and medication triggers including tetracyclines, retinoids, lithium, and growth hormone.
Key history
- Ask about headache, transient visual obscurations, pulsatile tinnitus, diplopia, nausea/vomiting, positional symptoms, weight change, pregnancy, and medication triggers including tetracyclines, retinoids, lithium, and growth hormone.
Exam findings
- Track acuity, pupils/APD, color, motility/abduction deficit, visual fields, and disc edema grade; OCT RNFL/GCC and fundus photos help monitor change.
Workup
- True papilledema generally requires urgent neuroimaging before lumbar puncture and evaluation for secondary causes such as mass, venous sinus thrombosis, infection, medication, or malignant hypertension.
Trusted references
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Infectious Exposure Screen Review of systems - ROS prompt
Review of systems questions
- Infection Risk
- Tmax
- Fever onset
- Fever duration
- Pregnant sick contacts pets bites/scratches insect bites travel homelessness shelter drinking untreated water exposure to woods
- Incarceration environmental/home occupation recent meat
- Dairy
- Seafood consumption IVDU Immunocompromise/cancer fam hx of immunocompromise HIV
- STI risk childhood vaccines Covid Vaccine
- Hx of Tb Tb exposure Recent hospitalizations Urethral foley Lines present on admission Current antibiotic use Recent antibiotic use Antacid drugs Allergies
Posterior Subcapsular Cataract Risk Screen Review of systems - ROS prompt
Review of systems questions
- History of diabetes
- Steroid use
- Trauma
- Radiation
- Hx/sx of ocular inflammation.
Stye / Eyelid Swelling Red-Flag Screen Review of systems - ROS prompt
Review of systems questions
- Eyelid/facial trauma
- Eyelid surgeries
- Insect bites
- Visual changes
- Flashes/floaters
- Double vision
- Pain with eye movement
- fevers
- Chills
- Night sweats.
Thyroid Eye Disease Symptom Screen Review of systems - ROS prompt
Review of systems questions
- A rapid pulse
- Hot and dry skin
- Diffusely enlarged thyroid gland (goiter)
- Weight loss
- Muscle wasting with proximal muscle weakness
- Hand tremor
- Pretibial dermopathy or myxedema
- Cardiac arrhythmias
- Change in bowel habits
- thyroid history.
Uveitis Review of Systems Review of systems - ROS prompt
Review of systems questions
- fevers
- Chills
- Night sweats
- Unexpected weight change
- Cough
- Shortness of breath
- Abdominal pain
- Urinary changes
- Diarrhea
- Blood in urine/stool
- Skin rashes
- Oral or genital ulcers
- joint pain
- recent international travel or sick contacts
- prior STD or high risk sexual activities reported
- tick bites or cat exposure
- hx of chickenpox
- Shingles
Viral Conjunctivitis / Epidemic Keratoconjunctivitis Ocular surface and adnexa - Patient education + clinical checklist
Red eye with discharge, eyelids stuck or crusted on waking, and foreign-body sensation with less than 4 weeks of symptoms supports acute conjunctivitis.
Key history
- Red eye with discharge, eyelids stuck or crusted on waking, and foreign-body sensation with less than 4 weeks of symptoms supports acute conjunctivitis.
- Watery discharge, recent upper respiratory infection, sick contact, one eye followed by the fellow eye, follicles, or preauricular node favors viral/EKC.
- Hyperacute severe purulent discharge raises concern for gonococcal conjunctivitis; chronic follicular disease should prompt consideration of chlamydia, molluscum, toxic, or masquerade causes.
Exam findings
- Document discharge type, follicular versus papillary reaction, preauricular node, eyelid edema, membranes/pseudomembranes, corneal staining, and anterior chamber reaction.
- Absence of corneal ulceration, thinning, or intraocular inflammation supports uncomplicated conjunctivitis.
Management
- Supportive care and infection precautions are appropriate for most viral conjunctivitis.
- Use topical antibiotic therapy when bacterial conjunctivitis is likely; culture severe, recurrent, recalcitrant, or gonococcal-concern cases.
- Do not let a conjunctivitis label obscure contact lens risk, corneal opacity, photophobia, significant pain, decreased vision, or herpetic skin/corneal findings.
Follow up
- Return urgently for pain, photophobia, worsening vision, increasing discharge, corneal opacity, or failure to improve.
Trusted references
Acute Conjunctivitis Ocular surface and adnexa - Clinical checklist
Red eye with discharge, eyelids stuck or crusted on waking, and foreign-body sensation with less than 4 weeks of symptoms supports acute conjunctivitis.
Key history
- Red eye with discharge, eyelids stuck or crusted on waking, and foreign-body sensation with less than 4 weeks of symptoms supports acute conjunctivitis.
- Watery discharge, recent upper respiratory infection, sick contact, one eye followed by the fellow eye, follicles, or preauricular node favors viral/EKC.
- Hyperacute severe purulent discharge raises concern for gonococcal conjunctivitis; chronic follicular disease should prompt consideration of chlamydia, molluscum, toxic, or masquerade causes.
Exam findings
- Document discharge type, follicular versus papillary reaction, preauricular node, eyelid edema, membranes/pseudomembranes, corneal staining, and anterior chamber reaction.
- Absence of corneal ulceration, thinning, or intraocular inflammation supports uncomplicated conjunctivitis.
Management
- Supportive care and infection precautions are appropriate for most viral conjunctivitis.
- Use topical antibiotic therapy when bacterial conjunctivitis is likely; culture severe, recurrent, recalcitrant, or gonococcal-concern cases.
- Do not let a conjunctivitis label obscure contact lens risk, corneal opacity, photophobia, significant pain, decreased vision, or herpetic skin/corneal findings.
Follow up
- Return urgently for pain, photophobia, worsening vision, increasing discharge, corneal opacity, or failure to improve.
Trusted references
Allergic Conjunctivitis Ocular surface and adnexa - Patient education + clinical checklist
Itching, watery discharge, bilateral symptoms, seasonal or allergen exposure, and personal atopy support allergic conjunctivitis.
Key history
- Itching, watery discharge, bilateral symptoms, seasonal or allergen exposure, and personal atopy support allergic conjunctivitis.
Exam findings
- Papillary conjunctival reaction, chemosis, eyelid edema, and watery discharge are typical; corneal involvement suggests more severe allergic disease.
Follow up
- Reassess sooner for pain, photophobia, decreased vision, corneal staining, or failure to improve.
Trusted references
Benign Essential Blepharospasm Ocular surface and adnexa - Clinical checklist
Progressive involuntary blinking, twitching, or eyelid closure suggests benign essential blepharospasm.
Key history
- Progressive involuntary blinking, twitching, or eyelid closure suggests benign essential blepharospasm.
Exam findings
- Orbicularis oculi spasms occur without full hemifacial contracture.
Management
- Oculoplastics or neuro-ophthalmology evaluation is appropriate when symptoms impair function; botulinum toxin is commonly considered.
Trusted references
Blepharitis Ocular surface and adnexa - Patient education + clinical checklist
Chronic or recurrent eyelid irritation, burning, crusting, flaking, gritty sensation, tearing, and fluctuating blur support blepharitis.
Key history
- Chronic or recurrent eyelid irritation, burning, crusting, flaking, gritty sensation, tearing, and fluctuating blur support blepharitis.
Exam findings
- Look for lid-margin erythema, lash collarettes or flakes, meibomian gland dysfunction, capped glands, telangiectasia, and associated punctate keratopathy.
Management
- Warm compresses, lid hygiene, artificial tears, and treatment of associated meibomian gland dysfunction or rosacea are core measures.
Trusted references
Chronic Conjunctivitis Ocular surface and adnexa - Clinical checklist
Red eye with discharge, eyelids stuck or crusted on waking, and foreign-body sensation with less than 4 weeks of symptoms supports acute conjunctivitis.
Key history
- Red eye with discharge, eyelids stuck or crusted on waking, and foreign-body sensation with less than 4 weeks of symptoms supports acute conjunctivitis.
- Watery discharge, recent upper respiratory infection, sick contact, one eye followed by the fellow eye, follicles, or preauricular node favors viral/EKC.
- Hyperacute severe purulent discharge raises concern for gonococcal conjunctivitis; chronic follicular disease should prompt consideration of chlamydia, molluscum, toxic, or masquerade causes.
Exam findings
- Document discharge type, follicular versus papillary reaction, preauricular node, eyelid edema, membranes/pseudomembranes, corneal staining, and anterior chamber reaction.
- Absence of corneal ulceration, thinning, or intraocular inflammation supports uncomplicated conjunctivitis.
Management
- Supportive care and infection precautions are appropriate for most viral conjunctivitis.
- Use topical antibiotic therapy when bacterial conjunctivitis is likely; culture severe, recurrent, recalcitrant, or gonococcal-concern cases.
- Do not let a conjunctivitis label obscure contact lens risk, corneal opacity, photophobia, significant pain, decreased vision, or herpetic skin/corneal findings.
Follow up
- Return urgently for pain, photophobia, worsening vision, increasing discharge, corneal opacity, or failure to improve.
Trusted references
Contact Lens Overwear Ocular surface and adnexa - Patient education + clinical checklist
Reports sleeping in contacts yesterday, awoke and took out contacts, now today with light sensitivity and redness
Key history
- Reports sleeping in contacts yesterday, awoke and took out contacts, now today with light sensitivity and redness
Exam findings
- No focal infiltrates, subepithelial infiltrates present centrally
Management
- Cool compresses for comfort
Trusted references
HSV Dermatitis Ocular surface and adnexa - Patient education + clinical checklist
First episode, no immunosuppression or systemic spread
Key history
- First episode, no immunosuppression or systemic spread
Exam findings
- Grouped vesicles on erythematous base, localized but not dermatomal, no ocular involvement
Trusted references
Ocular Rosacea Ocular surface and adnexa - Patient education + clinical checklist
Bilateral chronic ocular irritation, dry eyes, redness, burning, photophobia, and foreign body sensation. associated recurrent facial flushing episodes, persistent midfacial erythema, and papular skin lesions
Key history
- Bilateral chronic ocular irritation, dry eyes, redness, burning, photophobia, and foreign body sensation. associated recurrent facial flushing episodes, persistent midfacial erythema, and papular skin lesions
- Hx of blepharitis, chalazion
Exam findings
- Telangiectasias, pustules, papules, erythema of the cheeks, forehead, and nose, nasal rhinophyma
- Conjunctival injection. SPK, corneal vascularization (inferior cornea), stromal infiltrate, phlyctenules, perilimbal infiltrates of staphylococcal hypersensitivity, iritis
- Presentation most consistent with ocular rosacea
- Bilateral so less likely HSV keratitis. DES, PUK also on ddx
- Provoking factors: hot beverages, tobacco, vasodilating medications, alcohol, emotional stress
- No corneal thinning or infiltrates
- Start oral antibiotics, topical lubrication, lid hygiene
Trusted references
Pinguecula / Pterygium Ocular surface and adnexa - Patient education + clinical checklist
Pinguecula/Pingueculitits Presented with irritation, redness, and decreased vision
Key history
- Pinguecula/Pingueculitits Presented with irritation, redness, and decreased vision
Exam findings
- Yellow-white, slightly raised conjunctival lesion at nasal perilimbal conjunctiva; fluorescein reveals
- Pinguecula, inflamed / noninflamed
Trusted references
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Pterygium Ocular surface and adnexa - Patient education
A pterygium is a noncancerous growth that starts in the clear, thin tissue (conjunctiva) of the eye
Key history
- A pterygium is a noncancerous growth that starts in the clear, thin tissue (conjunctiva) of the eye
- This growth covers the white part of the eye (sclera) and extends onto the cornea
- It is often slightly raised and contains visible blood vessels
- The problem may occur on one or both eyes.The exact cause is unknown
- It is more common in people who have a lot of exposure to sunlight and wind, such as people who work outdoors
- Risk factors are exposure to sunny, dusty, sandy, or windblown areas
- Farmers, fishermen, and people living near the equator are often affected
Management
- In most cases,
- Involves only wearing sunglasses and using artificial tears
- Using artificial tears to keep the eyes moist may help prevent a pterygium from becoming inflamed and getting bigger
- Mild steroid eye drops can be used to calm inflammation if it occurs
- Surgery can be used to remove the growth for cosmetic reasons or if it blocks vision.Outlook (Prognosis) Most pterygia cause no problems and do not need surgical treatment
- If a pterygium affects the cornea, removing it can have good results
Trusted references
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Pterygium Ocular surface and adnexa - Clinical checklist
Presented with irritation, redness, and decreased vision
Key history
- Presented with irritation, redness, and decreased vision
Exam findings
- No visual axis encroachment. there is no corneal thinning
- No leukoplakic or papillomatous features
Trusted references
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Refractive Error-With history of contact lens/glasses use. Ocular surface and adnexa - Clinical checklist
Blur at distance, near, or both that improves with pinhole supports refractive error.
Key history
- Blur at distance, near, or both that improves with pinhole supports refractive error.
Exam findings
- Refraction determines the lens prescription; otherwise normal ocular exam supports uncomplicated refractive blur.
Differential
- Do not attribute decreased vision to refractive error when pinhole does not improve vision or when pain, photophobia, neurologic symptoms, media opacity, retinal disease, or optic neuropathy signs are present.
Trusted references
Stye / Hordeolum / Chalazion Ocular surface and adnexa - Patient education + clinical checklist
No madarosis, poliosis, and ulceration
Exam findings
- No madarosis, poliosis, and ulceration
Follow up
- Eye clinic Oculoplastics chalazion clinic in 2-3 weeks if not resolved
Trusted references
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Superior Limbic Keratoconjunctivitis Ocular surface and adnexa - Clinical checklist
Look for superior bulbar conjunctival hyperemia, superior tarsal micropapillae, redundant or thickened superior bulbar conjunctiva, and superior punctate staining.
Exam findings
- Look for superior bulbar conjunctival hyperemia, superior tarsal micropapillae, redundant or thickened superior bulbar conjunctiva, and superior punctate staining.
- Upper-quadrant corneal erosions can occur.
Management
- Treat ocular surface inflammation and friction; options in specialist care include lubrication, anti-inflammatory drops, therapeutic lenses, punctal occlusion, or procedural therapy for refractory disease.
Trusted references
Superior Limbic Keratoconjunctivitis (SLK) Ocular surface and adnexa - Patient education
Look for superior bulbar conjunctival hyperemia, superior tarsal micropapillae, redundant or thickened superior bulbar conjunctiva, and superior punctate staining.
Exam findings
- Look for superior bulbar conjunctival hyperemia, superior tarsal micropapillae, redundant or thickened superior bulbar conjunctiva, and superior punctate staining.
- Upper-quadrant corneal erosions can occur.
Management
- Treat ocular surface inflammation and friction; options in specialist care include lubrication, anti-inflammatory drops, therapeutic lenses, punctal occlusion, or procedural therapy for refractory disease.
Trusted references
VZV Dermatitis Ocular surface and adnexa - Patient education + clinical checklist
Painful unilateral V1 dermatomal rash, prodrome, eye pain, tearing, redness, decreased vision, immunosuppression, and age-related risk support HZO.
Key history
- Painful unilateral V1 dermatomal rash, prodrome, eye pain, tearing, redness, decreased vision, immunosuppression, and age-related risk support HZO.
Exam findings
- Inspect eyelids, scalp, and nose for vesicles or Hutchinson sign; assess corneal sensation, fluorescein staining, keratitis, uveitis, IOP, and posterior segment involvement.
Management
- Prompt systemic antiviral therapy and ophthalmology follow-up are important when HZO is suspected, especially with ocular symptoms or Hutchinson sign.
- Topical steroid decisions depend on ocular inflammation pattern and should be directed by ophthalmology.
Trusted references
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Band Keratopathy Cornea and external disease - Clinical checklist
Gray-white anterior calcium plaque at Bowman's layer, typically in the interpalpebral fissure with a clear zone near the limbus.
Exam findings
- Gray-white anterior calcium plaque at Bowman's layer, typically in the interpalpebral fissure with a clear zone near the limbus.
- Lucid spaces within the plaque support the diagnosis.
Workup
- If no ocular cause is evident, consider calcium, albumin, magnesium, phosphate, parathyroid hormone, renal function, uric acid, and sarcoid-directed testing based on clinical context.
Differential
- Common associations include chronic uveitis, corneal edema, trauma, phthisis, long-standing glaucoma, dry eye, ocular surgery, silicone oil exposure, and idiopathic disease.
- Systemic associations to consider include hypercalcemia, renal failure, sarcoidosis, multiple myeloma, vitamin D excess, hyperphosphatemia, gout, and corneal dystrophy.
Management
- Lubrication can help surface symptoms; visually significant or symptomatic plaques may need cornea follow-up for EDTA chelation or superficial keratectomy.
Trusted references
Chemical Keratopathy Cornea and external disease - Patient education
Identify the chemical, timing, duration of exposure, first irrigation, contact lens use, and whether particulate material may remain in the fornices.
Key history
- Identify the chemical, timing, duration of exposure, first irrigation, contact lens use, and whether particulate material may remain in the fornices.
Exam findings
- Check ocular pH before a complete exam when safe; document visual acuity, epithelial defect, corneal haze, conjunctival ischemia, limbal involvement, IOP, and fornix debris.
Management
- Immediate copious irrigation is the priority and should continue until physiologic pH is restored and stable after recheck.
- Sweep fornices and remove retained particulate matter because residual chemical can keep altering pH.
Follow up
- Severe pain, decreased vision, corneal haze, limbal ischemia, high IOP, or persistent epithelial defect requires urgent ophthalmology management.
Trusted references
Concern for peripheral ulcerative keratitis Cornea and external disease - Clinical checklist
Pain, redness, tearing, photophobia, decreased vision, autoimmune disease, rheumatoid arthritis, ANCA vasculitis, inflammatory bowel disease, infection risk, or prior corneal thinning are key history points.
Key history
- Pain, redness, tearing, photophobia, decreased vision, autoimmune disease, rheumatoid arthritis, ANCA vasculitis, inflammatory bowel disease, infection risk, or prior corneal thinning are key history points.
Exam findings
- Crescentic juxtalimbal stromal thinning with epithelial defect and inflammation supports PUK.
- Document thinning depth, epithelial defect, infiltrate, scleritis, descemetocele, perforation, anterior chamber reaction, and posterior scleritis signs.
Workup
- Evaluate for systemic autoimmune disease and infection when suspected; common testing includes CBC, CMP, urinalysis, ANA, ANCA, RF/anti-CCP, syphilis testing, chest imaging, hepatitis testing, and corneal culture when infection is possible.
Management
- Goals are to control inflammation, prevent superinfection, promote epithelial healing, and prevent perforation.
- Cornea and rheumatology coordination is often needed because systemic immunosuppression may be required.
Trusted references
Conjunctival Foreign Body Cornea and external disease - Patient education + clinical checklist
Use fluorescein staining, lid eversion, and careful inspection for retained foreign body, rust ring, infiltrate, Seidel positivity, and open-globe signs.
Exam findings
- Use fluorescein staining, lid eversion, and careful inspection for retained foreign body, rust ring, infiltrate, Seidel positivity, and open-globe signs.
Management
- Remove accessible superficial foreign material when appropriate, lubricate, use infection prophylaxis when indicated, and stop contact lens wear until healed.
Follow up
- Recheck promptly for persistent foreign-body sensation, worsening pain, photophobia, discharge, decreased vision, contact lens risk, metal injury, or plant/contaminated exposure.
Trusted references
Corneal Abrasion Cornea and external disease - Patient education + clinical checklist
Use fluorescein staining, lid eversion, and careful inspection for retained foreign body, rust ring, infiltrate, Seidel positivity, and open-globe signs.
Exam findings
- Use fluorescein staining, lid eversion, and careful inspection for retained foreign body, rust ring, infiltrate, Seidel positivity, and open-globe signs.
Management
- Remove accessible superficial foreign material when appropriate, lubricate, use infection prophylaxis when indicated, and stop contact lens wear until healed.
Follow up
- Recheck promptly for persistent foreign-body sensation, worsening pain, photophobia, discharge, decreased vision, contact lens risk, metal injury, or plant/contaminated exposure.
Trusted references
Corneal Delle Cornea and external disease - Patient education
Ask about recent ocular surgery, trauma, contact lens wear, exposure or lagophthalmos, and paralimbal elevation such as pterygium, pinguecula, chemosis, bleb, or conjunctival lesion.
Key history
- Ask about recent ocular surgery, trauma, contact lens wear, exposure or lagophthalmos, and paralimbal elevation such as pterygium, pinguecula, chemosis, bleb, or conjunctival lesion.
- Symptoms can include redness, foreign-body sensation, and grittiness.
Exam findings
- Peripheral saucer-shaped corneal thinning or depression with defined margins and fluorescein pooling suggests dellen.
- The epithelium may be intact over dehydrated stroma; adjacent tear-film disruption or limbal elevation is often present.
Management
- Rehydrate and protect the ocular surface with frequent lubrication, ointment, patching or bandage contact lens when appropriate, and treat the underlying paralimbal elevation or exposure.
Trusted references
Corneal Graft Rejection Cornea and external disease - Patient education + clinical checklist
Decreased vision, mild pain, redness, tearing, and photophobia
Key history
- Decreased vision, mild pain, redness, tearing, and photophobia
- Hx of corneal transplant in
- Exam- Epithelial edema
- Line of keratic precipitates on the corneal endothelium (endothelial rejection line / Khodadoust line)
- Subepithelial infiltrates (Krachmer spots)
- Irregularly elevated epithelial line (epithelial rejection line)
- Localized stromal neovascularization
Exam findings
- Presentation consistent with corneal graft rejection
Differential
- Oral steroids (dw cornea)
Trusted references
Corneal Hydrops (swelling) Cornea and external disease - Patient education
Sudden decreased vision, pain, and photophobia in keratoconus or other ectasia suggests acute corneal hydrops.
Key history
- Sudden decreased vision, pain, and photophobia in keratoconus or other ectasia suggests acute corneal hydrops.
- Ask about eye rubbing, atopy, coughing, sneezing, nose blowing, strenuous activity, and prior ectasia history.
Exam findings
- Assess visual acuity, corneal edema extent, anterior chamber view, and Seidel testing; IOP may be artifactually low when edema is severe.
Management
- Many cases are managed conservatively with cornea follow-up; topical therapy may include hypertonic saline, cycloplegia, steroid, antibiotic, or aqueous suppressant depending on findings.
- Large Descemet membrane separation or persistent severe edema may require procedural management such as intracameral air or gas by a cornea specialist.
Trusted references
Corneal Laceration Cornea and external disease - Clinical checklist
Look for full-thickness wound, Seidel positivity, peaked or irregular pupil, shallow or deep anterior chamber asymmetry, hyphema, lens violation, uveal/vitreous prolapse, or intraocular foreign body.
Exam findings
- Look for full-thickness wound, Seidel positivity, peaked or irregular pupil, shallow or deep anterior chamber asymmetry, hyphema, lens violation, uveal/vitreous prolapse, or intraocular foreign body.
Management
- Protect the eye with a rigid shield, avoid pressure/patching, keep the patient NPO when open globe is suspected, update tetanus, and arrange urgent ophthalmic repair.
- CT orbit can help assess foreign body or globe contour, but open globe remains a clinical diagnosis when suspicion is high.
Trusted references
Corneal Metallic Foreign Body Cornea and external disease - Patient education + clinical checklist
Use fluorescein staining, lid eversion, and careful inspection for retained foreign body, rust ring, infiltrate, Seidel positivity, and open-globe signs.
Exam findings
- Use fluorescein staining, lid eversion, and careful inspection for retained foreign body, rust ring, infiltrate, Seidel positivity, and open-globe signs.
Management
- Remove accessible superficial foreign material when appropriate, lubricate, use infection prophylaxis when indicated, and stop contact lens wear until healed.
Follow up
- Recheck promptly for persistent foreign-body sensation, worsening pain, photophobia, discharge, decreased vision, contact lens risk, metal injury, or plant/contaminated exposure.
Trusted references
Corneal Ulcer Cornea and external disease - Patient education + clinical checklist
Risk factors include contact lens wear, overnight lens use, water exposure, trauma, severe dry eye, eyelid disease, herpetic disease, steroid use, and immunosuppression.
Key history
- Risk factors include contact lens wear, overnight lens use, water exposure, trauma, severe dry eye, eyelid disease, herpetic disease, steroid use, and immunosuppression.
Exam findings
- A corneal epithelial defect with stromal infiltrate, fluorescein staining, circumcorneal injection, thinning, or hypopyon is concerning for microbial keratitis.
Management
- Central, large, deep, atypical, severe, contact-lens related, or refractory ulcers often require culture and intensive topical antimicrobial therapy.
- Do not patch infectious keratitis; avoid topical steroids unless a cornea specialist directs timing.
Trusted references
Delle Cornea and external disease - Clinical checklist
Irritation and foreign body sensation
Key history
- Irritation and foreign body sensation
- Associated fluorescein pooling/staining
- No infiltrate, no anterior chamber reaction
Exam findings
- Corneal delle, associated conjunctival / corneal elevation
- Poor tear film coverage with resultant stromal dehydration
Trusted references
Exposure Keratopathy Cornea and external disease - Clinical checklist
/2 to Bell's Palsy
Key history
- /2 to Bell's Palsy
- Per patient they was admitted and worked up for etiology
Exam findings
- Exam significant for 2+ IPF SPK, OS no corneal abrasion or ulcer
- Left lower lid ectropion
Follow up
- Local ophthalmology within 2 weeks- If medical therapy fails, recommend following up with Oculoplastics, to consider external weights, temp tarsorrhaphy, ectropion repair, palpebral spring, levator botox injection
Trusted references
Filamentary keratitis Cornea and external disease - Clinical checklist
Hx of chronic redness, photophobia, pain
Key history
- Hx of chronic redness, photophobia, pain
Exam findings
- Scattered mucoepithelioid strands with underlying gray subepithelial haze
- Etiology likely 2/2 severe ocular dryness
Trusted references
Fuchs Endothelial Corneal Dystrophy Cornea and external disease - Patient education + clinical checklist
Glare and blurred vision that is worse on awakening are classic symptoms; painful bullae can occur in advanced disease.
Key history
- Glare and blurred vision that is worse on awakening are classic symptoms; painful bullae can occur in advanced disease.
Exam findings
- Look for corneal guttae, stromal or epithelial edema, Descemet folds, epithelial bullae, and reduced corneal clarity.
Management
- Hypertonic saline and lubrication may help symptoms; visually significant edema or painful bullae require cornea follow-up.
Trusted references
HSV Keratitis Cornea and external disease - Patient education + clinical checklist
Red eye, pain, foreign-body sensation, photophobia, tearing, decreased vision, prior HSV, recent steroid use, or periocular vesicles support HSV keratitis.
Key history
- Red eye, pain, foreign-body sensation, photophobia, tearing, decreased vision, prior HSV, recent steroid use, or periocular vesicles support HSV keratitis.
Exam findings
- Epithelial dendrites or geographic ulcers, reduced corneal sensation, stromal infiltrate, keratic precipitates, anterior chamber inflammation, or elevated IOP may occur depending on subtype.
Management
- Antiviral therapy is central; topical steroids should be avoided in active epithelial disease unless directed by ophthalmology.
Trusted references
Interstitial Keratitis Cornea and external disease - Patient education
Means there is swelling and scarring in the middle layer of your cornea
Key history
- Means there is swelling and scarring in the middle layer of your cornea
- This can cause blurry vision, redness, and light sensitivity
- We started you on medicine to help
- You need to see a cornea specialist for continued care
Trusted references
Keratoconus Acute corneal hydrops Cornea and external disease - Clinical checklist
Sudden decreased vision, pain, and photophobia in keratoconus or other ectasia suggests acute corneal hydrops.
Key history
- Sudden decreased vision, pain, and photophobia in keratoconus or other ectasia suggests acute corneal hydrops.
- Ask about eye rubbing, atopy, coughing, sneezing, nose blowing, strenuous activity, and prior ectasia history.
Exam findings
- Assess visual acuity, corneal edema extent, anterior chamber view, and Seidel testing; IOP may be artifactually low when edema is severe.
Management
- Many cases are managed conservatively with cornea follow-up; topical therapy may include hypertonic saline, cycloplegia, steroid, antibiotic, or aqueous suppressant depending on findings.
- Large Descemet membrane separation or persistent severe edema may require procedural management such as intracameral air or gas by a cornea specialist.
Trusted references
Peripheral Corneal Thinning/Ulceration Cornea and external disease - Patient education
Pain, redness, tearing, photophobia, decreased vision, autoimmune disease, rheumatoid arthritis, ANCA vasculitis, inflammatory bowel disease, infection risk, or prior corneal thinning are key history points.
Key history
- Pain, redness, tearing, photophobia, decreased vision, autoimmune disease, rheumatoid arthritis, ANCA vasculitis, inflammatory bowel disease, infection risk, or prior corneal thinning are key history points.
Exam findings
- Crescentic juxtalimbal stromal thinning with epithelial defect and inflammation supports PUK.
- Document thinning depth, epithelial defect, infiltrate, scleritis, descemetocele, perforation, anterior chamber reaction, and posterior scleritis signs.
Workup
- Evaluate for systemic autoimmune disease and infection when suspected; common testing includes CBC, CMP, urinalysis, ANA, ANCA, RF/anti-CCP, syphilis testing, chest imaging, hepatitis testing, and corneal culture when infection is possible.
Management
- Goals are to control inflammation, prevent superinfection, promote epithelial healing, and prevent perforation.
- Cornea and rheumatology coordination is often needed because systemic immunosuppression may be required.
Trusted references
Peripheral Corneal ThinningConcern for Mooren Ulcer Cornea and external disease - Clinical checklist
Pain, redness, tearing, photophobia, decreased vision, autoimmune disease, rheumatoid arthritis, ANCA vasculitis, inflammatory bowel disease, infection risk, or prior corneal thinning are key history points.
Key history
- Pain, redness, tearing, photophobia, decreased vision, autoimmune disease, rheumatoid arthritis, ANCA vasculitis, inflammatory bowel disease, infection risk, or prior corneal thinning are key history points.
Exam findings
- Crescentic juxtalimbal stromal thinning with epithelial defect and inflammation supports PUK.
- Document thinning depth, epithelial defect, infiltrate, scleritis, descemetocele, perforation, anterior chamber reaction, and posterior scleritis signs.
Workup
- Evaluate for systemic autoimmune disease and infection when suspected; common testing includes CBC, CMP, urinalysis, ANA, ANCA, RF/anti-CCP, syphilis testing, chest imaging, hepatitis testing, and corneal culture when infection is possible.
Management
- Goals are to control inflammation, prevent superinfection, promote epithelial healing, and prevent perforation.
- Cornea and rheumatology coordination is often needed because systemic immunosuppression may be required.
Trusted references
Photokeratitis / Ultraviolet Keratitis Cornea and external disease - Patient education + clinical checklist
Photokeratitis OU- Hx of occupational exposure, not wearing protective glasses
Key history
- Photokeratitis OU- Hx of occupational exposure, not wearing protective glasses
Exam findings
- Oral analgesia as needed- Defer BCL given unclear
Follow up
- Adherence at this time
- Counseled on diagnosis and precautions
Trusted references
Pseudophakic / Aphakic Bullous Keratopathy Cornea and external disease - Patient education + clinical checklist
Decreased vision, pain, tearing, foreign body sensation, photophobia, and redness
Key history
- Decreased vision, pain, tearing, foreign body sensation, photophobia, and redness
- History of cataract surgery in the involved eye.Exam- Corneal edema, Corneal bullae, Descemet folds, subepithelial haze or scarring, corneal neovascularization, with or without preexisting guttae
- Cystoid macular edema (CME)
Exam findings
- Presentation c/f pseudophakic bullous keratopathy
Trusted references
Recurrent Corneal Erosion Cornea and external disease - Clinical checklist
Ocular pain, photophobia, foreign body sensation, and tearing
Key history
- Ocular pain, photophobia, foreign body sensation, and tearing
- Has had recurrent episodes in the past, has hx of corneal abrasion in the involved eye
- Denies family history of corneal issue or recurrent corneal abrasion
- Denies ocular surgical hx
Exam findings
- Localized irregularity and mobility of the corneal epithelium (negative / positive staining), KED as measured above, no infiltrate
- Corneal epithelial dots or microcysts, epithelial fingerprint pattern epithelial map-like lines
- By history and exam, most consistent with recurrent corneal erosion
- Suspected predisposing condition: prior corneal abrasion, EBMD, Reis
- Bcklers, Thiel
- Behnke, and Meesmann dystrophies, Lattice, granular, and macular dystrophies, Band keratopathy, Salzmann nodular degeneration, hx of ocular surgery (Keratorefractive, corneal transplant, cataract surgery)
- Start cycloplegia, topical antibiotics, topical Na Cl
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Staph Marginal Keratitis Cornea and external disease - Patient education
Pain, foreign-body sensation, photophobia, injection, recurrent episodes, and blepharitis symptoms support staphylococcal marginal keratitis.
Key history
- Pain, foreign-body sensation, photophobia, injection, recurrent episodes, and blepharitis symptoms support staphylococcal marginal keratitis.
Exam findings
- Peripheral stromal infiltrates parallel to the limbus with a clear zone of intervening cornea are typical.
- Epithelial defect or ulceration requires care to distinguish sterile marginal disease from infectious keratitis.
Management
- Control eyelid bacterial antigen burden with lid hygiene and blepharitis management.
- Topical anti-inflammatory therapy may be used when infection is not suspected; epithelial defects often require antibiotic coverage and close monitoring.
Trusted references
Superficial punctate keratitis Cornea and external disease - Patient education
Pain, tearing, photophobia, redness, gritty or foreign-body sensation, burning, contact lens wear, dry eye, blepharitis, viral conjunctivitis, UV exposure, chemical exposure, medication toxicity, and exposure risk help identify the cause.
Key history
- Pain, tearing, photophobia, redness, gritty or foreign-body sensation, burning, contact lens wear, dry eye, blepharitis, viral conjunctivitis, UV exposure, chemical exposure, medication toxicity, and exposure risk help identify the cause.
Exam findings
- Slit-lamp exam with fluorescein shows scattered fine punctate epithelial staining or epithelial loss.
Management
- Treatment depends on the cause; address dry eye, blepharitis, viral/toxic exposure, contact lens risk, UV keratitis, or chemical injury rather than treating SPK as a single diagnosis.
Trusted references
Terrien marginal degeneration Cornea and external disease - Clinical checklist
Pain, photophobia, red eye or
Key history
- Pain, photophobia, red eye or
- Denies CL use, HSV/VZV keratitis, connective tissue disorder, inflammatory bowel disease, seasonal allergies, prior ocular surgery
Exam findings
- Bilateral thinning of the peripheral cornea; superior distribution from
- Lipid line with fine pannus along the central edge of the thinning
- The anterior chamber is quiet
- Peripheral corneal thinning most consistent with terrien marginal degeneration
- Broad ddx for peripheral corneal thinning also considered
- No epi defect or infiltrate, as such no antibiotics or cultures indicated
- Would benefit from polycarbs
Follow up
- Cornea 1 day
Trusted references
Thygeson Cornea and external disease - Clinical checklist
Chronic recurrent foreign-body sensation, photophobia, tearing, and remitting exacerbations with little conjunctival injection support Thygeson superficial punctate keratitis.
Key history
- Chronic recurrent foreign-body sensation, photophobia, tearing, and remitting exacerbations with little conjunctival injection support Thygeson superficial punctate keratitis.
Exam findings
- Small, elevated, gray-white, coarse central epithelial opacities with light fluorescein staining are typical.
- There should be little or no conjunctival inflammation, corneal edema, anterior chamber reaction, or eyelid abnormality.
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Thygeson superficial punctate keratitis Cornea and external disease - Patient education
Pain, tearing, photophobia, redness, gritty or foreign-body sensation, burning, contact lens wear, dry eye, blepharitis, viral conjunctivitis, UV exposure, chemical exposure, medication toxicity, and exposure risk help identify the cause.
Key history
- Pain, tearing, photophobia, redness, gritty or foreign-body sensation, burning, contact lens wear, dry eye, blepharitis, viral conjunctivitis, UV exposure, chemical exposure, medication toxicity, and exposure risk help identify the cause.
Exam findings
- Slit-lamp exam with fluorescein shows scattered fine punctate epithelial staining or epithelial loss.
Management
- Treatment depends on the cause; address dry eye, blepharitis, viral/toxic exposure, contact lens risk, UV keratitis, or chemical injury rather than treating SPK as a single diagnosis.
Trusted references
VZV Keratitis Cornea and external disease - Clinical checklist
Is immunocompetent, reports no prior episodes
Key history
- Is immunocompetent, reports no prior episodes
Exam findings
- No APD, CP full, IOP wnl, EOM full, CVF full
Workup
- Evidence of vesicular rash in V1 distribution,
- **Decreased corneal sensitivity
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Anterior Uveitis / Iritis Inflammation and uveitis - Patient education + clinical checklist
Management
- SI joint films
- Consider HSV/VZV serologies
- CMV serum PCR Juvenile idiopathic arthritis: RF
- Joint X-rays
- Rheum derm consult Reactive arthritis: HLA-B27
- SI films if symptomatic
- PPD/IGRA
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APMPPE Inflammation and uveitis - Clinical checklist
Acute bilateral visual loss after viral illness- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
Key history
- Acute bilateral visual loss after viral illness- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
Workup
- May be associated with a cerebral vasculitis
Trusted references
ARN Inflammation and uveitis - Clinical checklist
Panuveitis, ARN- Acute unilateral vision loss, redness, blurred vision, floaters, ocular pain, and photophobia
Key history
- Panuveitis, ARN- Acute unilateral vision loss, redness, blurred vision, floaters, ocular pain, and photophobia
- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure- Denies cold sores, chicken pox, shingles, no shingles vaccine
Workup
- Goal is to halt and regress the retinitis in the involved eye and decrease the incidence of disease in the fellow eye
Management
- Does not reduce the rate of retinal detachment in the first eye
Follow up
- In retina tomorrow
Trusted references
Birdshot chorioretinopathy Inflammation and uveitis - Clinical checklist
Bilateral visual loss and floaters
Key history
- Bilateral visual loss and floaters
Workup
- HLA-A29 sent
Trusted references
CMV Inflammation and uveitis - Clinical checklist
Panuveitis, CMV retinitis- Scotoma or decreased vision in one or both eyes, floaters, or photopsias
Key history
- Panuveitis, CMV retinitis- Scotoma or decreased vision in one or both eyes, floaters, or photopsias
- Pain and photophobia are uncommon
- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
Exam findings
- The absence of hemorrhage does not rule out CMV retinitis.- Fulminant form: Confluent areas of necrosis with prominent intraretinal hemorrhage, with perivascular infiltration along the major retinal vascular arcades
- Profound retinal vasculitis with severe vascular exudating affecting both the arterioles and venules.- Anterior uveitis with nongranulomatous
- Stellate KP almost always present but mild
- Vitritis is usually mild
Workup
- 2 to 3 mm of the disc
- Threatening a large retinal vessel) or lesions that are associated with severe vitritis causing decreased vision
- Disease in an immunocompromised patient
Follow up
- In retina tomorrow
Trusted references
Episcleritis Inflammation and uveitis - Patient education + clinical checklist
Severe boring eye pain, pain with eye movement, nighttime awakening, globe tenderness, radiating facial pain, and systemic autoimmune or vasculitic symptoms support scleritis.
Key history
- Severe boring eye pain, pain with eye movement, nighttime awakening, globe tenderness, radiating facial pain, and systemic autoimmune or vasculitic symptoms support scleritis.
Exam findings
- Violet-blue scleral hue, deep immobile vessels, scleral edema, tenderness, keratitis, uveitis, trabeculitis, or posterior segment findings help distinguish scleritis from episcleritis.
Workup
- Systemic evaluation is often needed for autoimmune, infectious, and vasculitic causes; B-scan or orbital imaging can help identify posterior scleritis.
Management
- Treatment aims to suppress inflammation and prevent ocular damage; systemic therapy is often required, especially for posterior, necrotizing, or systemic disease.
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Intermediate Uveitis Inflammation and uveitis - Patient education
Floaters and gradual blurred vision are typical; pain, photophobia, and red eye are less common than in anterior uveitis.
Key history
- Floaters and gradual blurred vision are typical; pain, photophobia, and red eye are less common than in anterior uveitis.
- Ask about sarcoidosis, tuberculosis, syphilis, Lyme disease, multiple sclerosis, Behcet disease, malignancy risk, and prior uveitis.
Exam findings
- Vitreous cells or haze, snowballs, snowbanking, peripheral vasculitis, cystoid macular edema, and optic disc edema support intermediate uveitis.
Workup
- Evaluation is guided by age, systemic symptoms, and exam; infectious, inflammatory, and masquerade causes should be excluded when suggested.
Management
- Observe mild asymptomatic disease with good vision; treat reduced vision, substantial vitritis, macular edema, retinal vasculitis, or other complications.
Trusted references
Intermediate Uveitis Inflammation and uveitis - Clinical checklist
Floaters and gradual blurred vision are typical; pain, photophobia, and red eye are less common than in anterior uveitis.
Key history
- Floaters and gradual blurred vision are typical; pain, photophobia, and red eye are less common than in anterior uveitis.
- Ask about sarcoidosis, tuberculosis, syphilis, Lyme disease, multiple sclerosis, Behcet disease, malignancy risk, and prior uveitis.
Exam findings
- Vitreous cells or haze, snowballs, snowbanking, peripheral vasculitis, cystoid macular edema, and optic disc edema support intermediate uveitis.
Workup
- Evaluation is guided by age, systemic symptoms, and exam; infectious, inflammatory, and masquerade causes should be excluded when suggested.
Management
- Observe mild asymptomatic disease with good vision; treat reduced vision, substantial vitritis, macular edema, retinal vasculitis, or other complications.
Trusted references
MEWDS Inflammation and uveitis - Clinical checklist
Unilateral photopsias and visual loss, often after a viral illness and usually in young women- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
Key history
- Unilateral photopsias and visual loss, often after a viral illness and usually in young women- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
Trusted references
Panuveitis Inflammation and uveitis - Clinical checklist
Red, painful eye
Key history
- Red, painful eye
- Moderate to severe vision loss
- Denies history of sexually transmitted diseases
- High-risk sexual activity
- Intravenous drug use
- Exposure to cats
- Neurologic symptoms (deficits or headaches)
Follow up
- Retina 1-2 days
Trusted references
Phlyctenulosis Inflammation and uveitis - Patient education + clinical checklist
Has a history of similar episodes, chalazia
Key history
- Has a history of similar episodes, chalazia
- No hx or high risk exposure c/f TB, coccidiomycosis, Candidiasis, lymphogranuloma venereum
Exam findings
- Limbal / perilimbal
- Associated surrounding hyperemia Corneal: small
- Limbal / central
- Associated dilated conjunctival blood vessels
- Corneal thinning. wedge-shaped corneal neovascularization
- Presentation most consistent with corneal / conjunctival phlyctenulosis
- Ddx also includes staph hypersensitivity, ocular rosacea
Trusted references
Posterior Uveitis Inflammation and uveitis - Clinical checklist
Blurred vision, floaters, scotomas, metamorphopsia, and photopsias
Key history
- Blurred vision, floaters, scotomas, metamorphopsia, and photopsias
- Denies history of sexually transmitted diseases
- High-risk sexual activity
- Intravenous drug use
- Exposure to cats
- Neurologic symptoms (deficits or headaches)
- History of cancer or immunosuppression
Follow up
- Retina 1-2 days
Trusted references
Rebound Iritis Inflammation and uveitis - Patient education + clinical checklist
Blurred vision, pain, photophobia, and redness after recent anterior uveitis treatment, steroid taper, steroid discontinuation, or ocular surgery supports rebound iritis.
Key history
- Blurred vision, pain, photophobia, and redness after recent anterior uveitis treatment, steroid taper, steroid discontinuation, or ocular surgery supports rebound iritis.
Exam findings
- Anterior chamber cell and flare with conjunctival injection and no corneal epithelial defect, hypopyon, vitritis, or posterior segment inflammation supports anterior rebound inflammation.
Differential
- Consider endophthalmitis, infectious keratitis, herpetic anterior uveitis, scleritis, and retained lens material when pain, hypopyon, vitritis, corneal lesion, or postoperative red flags are present.
Trusted references
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Scleritis Inflammation and uveitis - Patient education + clinical checklist
Severe boring eye pain, pain with eye movement, nighttime awakening, globe tenderness, radiating facial pain, and systemic autoimmune or vasculitic symptoms support scleritis.
Key history
- Severe boring eye pain, pain with eye movement, nighttime awakening, globe tenderness, radiating facial pain, and systemic autoimmune or vasculitic symptoms support scleritis.
Exam findings
- Violet-blue scleral hue, deep immobile vessels, scleral edema, tenderness, keratitis, uveitis, trabeculitis, or posterior segment findings help distinguish scleritis from episcleritis.
Workup
- Systemic evaluation is often needed for autoimmune, infectious, and vasculitic causes; B-scan or orbital imaging can help identify posterior scleritis.
Management
- Treatment aims to suppress inflammation and prevent ocular damage; systemic therapy is often required, especially for posterior, necrotizing, or systemic disease.
Trusted references
Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis Inflammation and uveitis - Clinical checklist
Erythema Multiforme / Stevens
Key history
- Erythema Multiforme / Stevens
- Johnson Syndrome / Toxic Epidermal Necrolysis Flu-like prodrome (fever, malaise, arthralgia, dysphagia), red eyes, eye pain/burning, and skin rash
- Reports recent illness
- No recent new drug exposures to Antibiotics (sulfonamides, penicillins, cephalosporins), anticonvulsants (carbamazepine, phenytoin, barbiturates), NSAIDs (oxicam type), allopurinol, corticosteroids within last 2 months
- No known allergies, no known autoimmune disease
- No hx of radiation therapy
- No hx of malignancy
Trusted references
Ocular Toxoplasmosis Inflammation and uveitis - Clinical checklist
Panuveitis, Toxoplasmosis- Blurred vision and floaters
Key history
- Panuveitis, Toxoplasmosis- Blurred vision and floaters
- May have redness and photophobia.- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
Workup
- 2 to 3 mm of the disc
- Threatening a large retinal vessel) or lesions that are associated with severe vitritis causing decreased vision
- Disease in an immunocompromised patient
Follow up
- In retina tomorrow
Trusted references
Traumatic Iritis Inflammation and uveitis - Patient education + clinical checklist
Presenting >48 hours after trauma to eye- Dull, aching, or throbbing pain, photophobia, tearing, redness, blurry vision
Key history
- Presenting >48 hours after trauma to eye- Dull, aching, or throbbing pain, photophobia, tearing, redness, blurry vision
Trusted references
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Uveitis-Glaucoma-Hyphema Syndrome Inflammation and uveitis - Clinical checklist
Most hyphemas follow blunt trauma; ask about sickle cell disease/trait, anticoagulants, bleeding disorders, and prior ocular surgery.
Key history
- Most hyphemas follow blunt trauma; ask about sickle cell disease/trait, anticoagulants, bleeding disorders, and prior ocular surgery.
Exam findings
- Grade the anterior chamber blood and check IOP after open globe is excluded.
Management
- Use shield and activity restriction; monitor closely for rebleeding and IOP elevation.
Trusted references
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Age-Related Macular Degeneration Retina and vitreous - Patient education + clinical checklist
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Central / Branch Retinal Artery Occlusion Retina and vitreous - Patient education + clinical checklist
VA CF, 2+ APD, CP unable, IOP wnl, EOM full, CVF full
Exam findings
- VA CF, 2+ APD, CP unable, IOP wnl, EOM full, CVF full
Workup
- Factor V Leiden
- Activated protein C resistance
- Protein C and S deficiency
- Antithrombin III mutation
- Obtain appropriate serologic testing to rule out Bartonella henselae
Trusted references
Central / Branch Retinal Vein Occlusion Retina and vitreous - Patient education + clinical checklist
C/BRVO, -Painless vision loss O
Key history
- C/BRVO, -Painless vision loss O
Exam findings
- Lipid panel- Ordered a hypercoagulable/vasculitis panel for the patient given mild vasculopathic risk factors (APC
- Anti-cardiolipin
- Factor V leiden
- SPEP/UPEP
- Lupus anticoagulation (B2
- Glycoprotein) Protein C/S, Prothrombin, RPR
Trusted references
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Central Serous Chorioretinopathy Retina and vitreous - Patient education + clinical checklist
Acute or subacute central blur, metamorphopsia, micropsia, central scotoma, reduced contrast or color saturation, steroid exposure, stress, sleep disturbance, and pregnancy are useful history points.
Key history
- Acute or subacute central blur, metamorphopsia, micropsia, central scotoma, reduced contrast or color saturation, steroid exposure, stress, sleep disturbance, and pregnancy are useful history points.
Exam findings
- Subretinal fluid at the macula on OCT supports CSCR; exam may show a serous neurosensory detachment.
Management
- Many acute cases are initially observed because spontaneous resolution is common; persistent, recurrent, chronic, or occupationally urgent cases need retina-directed therapy.
Trusted references
Choroidal Effusion/Detachment Retina and vitreous - Clinical checklist
No recent intraocular procedures, trauma, melanoma or cancer history- No sulfa drugs such as topiramate and diuretics, tetracycline antibiotics, or selective serotonin reuptake inhibitors
Key history
- No recent intraocular procedures, trauma, melanoma or cancer history- No sulfa drugs such as topiramate and diuretics, tetracycline antibiotics, or selective serotonin reuptake inhibitors
Differential
- No signs of any of these pathologies on exam or history
Management
- "Kissing" choroidals (apposition of two lobules of detached choroid) can usually be tolerated as long as there is not intractable pain or IOP elevation
Trusted references
Choroidal neovascularization Retina and vitreous - Clinical checklist
Blurry vision, metamorphopsia
Key history
- Blurry vision, metamorphopsia
- Denies hx of AMD, IVI, trauma, high myopia
Exam findings
- DFE w/ grey-yellow elevated macular lesion
- Distortion on amsler testing
- Suspect CNVM by exam and history
- Suspected etiologies: AMD, IVI, trauma, high myopia
- Requires further evaluation with retina specialist, OCT, possible OCT-A, FA
Trusted references
Choroidal Nevus Retina and vitreous - Patient education + clinical checklist
Incidentally noted on exam today
Key history
- Incidentally noted on exam today
- Per patient, not previously known
- Thickness, Fluid, Symptoms, Orange pigment, Margin, hollowness, halo absent, drusen absent
Trusted references
Commotio Retinae Retina and vitreous - Patient education + clinical checklist
Closed-globe or blast trauma with blur, scotoma, photopsias, or decreased vision raises concern for commotio retinae and associated injuries.
Key history
- Closed-globe or blast trauma with blur, scotoma, photopsias, or decreased vision raises concern for commotio retinae and associated injuries.
Management
- There is no standard medical treatment; follow with serial retinal exams to detect traumatic macular hole, tear, choroidal rupture, hyphema-related sequelae, or late retinal complications.
Trusted references
Diabetic Retinopathy Retina and vitreous - Patient education + clinical checklist
But less than severe NPDR
Exam findings
- But less than severe NPDR
- 2 quadrants of venous beading
- 1 quadrant of prominent intraretinal microvascular abnormalities
- Elsewhere in retina
- Vitreous/preretinal hemorrhage
Management
- PCP 1 week for DM control management- Given reduced Va, recommend
Follow up
- Dilated fundus examination every 6 to 12 months.Moderate NPDR
- Dilated fundus examination every 6 months.- Given severe/PDR stage, refer to retina 1 week for further testing and anti
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Dry Eye / Tear-Film Instability Retina and vitreous - Patient education + clinical checklist
Dry Eye OUForeign body sensation, burning, dryness, mildly to moderately decreased or fluctuating vision, and tearing
Key history
- Dry Eye OUForeign body sensation, burning, dryness, mildly to moderately decreased or fluctuating vision, and tearing
- Bilateral and chronic
Exam findings
- Decreased TBUT, +SPK, MGD, pain relief with proparacaine
Trusted references
Epiretinal Membrane Retina and vitreous - Clinical checklist
Decreased and distorted vision
Key history
- Decreased and distorted vision
Exam findings
- DFE w/ fine, glistening membrane (cellophane maculopathy) present on the surface of the retina in the macular area, retinal folds radiating out from the membrane
Follow up
- Return immediately if any sudden visual change is noted
Trusted references
Hemorrhagic Choroidal Detachment Retina and vitreous - Clinical checklist
Differential
- No signs of any of these pathologies on exam or history
Management
- More successful if hemorrhage is liquefied, which occurs 7 to 10 days after the initial event.- Farber clearance obtained
Trusted references
Hemorrhagic Posterior Vitreous Detachment Retina and vitreous - Clinical checklist
Ask about sudden new floaters, flashes, curtain/shadow, trauma, high myopia, prior tear/detachment, and cataract or retinal surgery.
Key history
- Ask about sudden new floaters, flashes, curtain/shadow, trauma, high myopia, prior tear/detachment, and cataract or retinal surgery.
Exam findings
- Dilated peripheral retinal exam is the key diagnostic step; B-scan is useful when the view is limited.
Management
- Retinal tear or detachment symptoms require urgent ophthalmic evaluation because prompt treatment protects vision.
Trusted references
Juvenile Retinoschisis Retina and vitreous - Clinical checklist
Degenerative retinoschisis is often asymptomatic; ask about flashes, floaters, field defect, family history, and symptoms suggesting retinal detachment.
Key history
- Degenerative retinoschisis is often asymptomatic; ask about flashes, floaters, field defect, family history, and symptoms suggesting retinal detachment.
Exam findings
- Smooth dome-shaped peripheral retinal splitting, commonly inferotemporal, with an absolute scotoma supports degenerative retinoschisis.
- Differentiate schisis cavity from rhegmatogenous retinal detachment and note inner or outer wall breaks.
Management
- Most degenerative retinoschisis is observed because progression is uncommon; treatment is reserved for selected progressive schisis detachment or retinal detachment scenarios.
Trusted references
Lattice Degeneration Retina and vitreous - Patient education
Follow up
- Appointment as directed by your doctor for a repeat dilated exam to ensure your exam does not change
Trusted references
Macular Hole vs. pseudohole vs. lamellar hole Retina and vitreous - Clinical checklist
Metamorphopsia, central blur, central scotoma, age over 60, myopia, trauma, inflammation, or symptoms of vitreomacular traction are relevant.
Key history
- Metamorphopsia, central blur, central scotoma, age over 60, myopia, trauma, inflammation, or symptoms of vitreomacular traction are relevant.
Exam findings
- OCT is the key test to distinguish full-thickness macular hole, lamellar macular hole, macular pseudohole, epiretinal membrane, and vitreomacular traction.
Management
- Observation is reasonable for many asymptomatic lamellar holes or early/stable findings; symptomatic progression or full-thickness macular hole warrants retina evaluation for possible surgery.
Trusted references
Multifocalchoroiditis Retina and vitreous - Clinical checklist
Multifocal Choroiditis (MFC), Visual loss in young myopic woman, bilateral- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
Key history
- Multifocal Choroiditis (MFC), Visual loss in young myopic woman, bilateral- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
Trusted references
Ocular Histoplasmosis, OU- Asymptomatic Retina and vitreous - Clinical checklist
Lived in the Ohio
Key history
- Lived in the Ohio
- Mississippi River Valley
Exam findings
- There may be a rim of pigment separating the disc from the area of atrophy or scarring
Differential
- OHS vs multifocal chorioretinitis; given lack of anterior or vitreous inflammatory cells, OHS probable
- Old toxoplasmosis and myopic degeneration but presentation less consistent with these diagnoses
Follow up
- Return immediately if any sudden visual change is noted
Trusted references
Polypoidal Choroidal Vasculopathy Retina and vitreous - Clinical checklist
Decreased central vision
Key history
- Decreased central vision
- Bilateral subretinal and/or sub
- RPE blood, VH, circinate subretinal exudates, subretinal fibrosis (disciform scar), SRF, atypical CNV, and multiple serous PEDs.Assessment History and exam concerning for polypoidal choroidal vasculopathy
Differential
- AMD, RAM, CNVM among others
- Recommend retina eval, consider ICGA, IVFA, OCT, possible anti-vegf
Follow up
- Retina 1-2 days
Trusted references
Posterior Vitreous Detachment Retina and vitreous - Patient education + clinical checklist
Ask about sudden new floaters, flashes, curtain/shadow, trauma, high myopia, prior tear/detachment, and cataract or retinal surgery.
Key history
- Ask about sudden new floaters, flashes, curtain/shadow, trauma, high myopia, prior tear/detachment, and cataract or retinal surgery.
Exam findings
- Dilated peripheral retinal exam is the key diagnostic step; B-scan is useful when the view is limited.
Management
- Retinal tear or detachment symptoms require urgent ophthalmic evaluation because prompt treatment protects vision.
Trusted references
Retinal Artery Macroaneurysm Retina and vitreous - Patient education
A small bulge formed in one of the blood vessels in your retina
Key history
- A small bulge formed in one of the blood vessels in your retina
- It can leak fluid or blood and may affect your central vision
- This conditions often happens in older adults or people with high blood pressure
Follow up
- You should see your primary care doctor for blood pressure management
Trusted references
Retinal Artery Macroaneurysm Retina and vitreous - Clinical checklist
Medical hx includes hypertension
Key history
- Medical hx includes hypertension
- No trauma, strain prior to vision loss Exam- BP
- No vasculitis or nerve involvement to suggest IRVAN
- No hx to suggest valsalva
- No macular findings in fellow eye to suggest alternative etiology
- Has hx of hypertension
Follow up
- Retina 3-5 days
- PCP 1 wk for hypertension management
Trusted references
Retinal Detachment Retina and vitreous - Patient education + clinical checklist
Ask about sudden new floaters, flashes, curtain/shadow, trauma, high myopia, prior tear/detachment, and cataract or retinal surgery.
Key history
- Ask about sudden new floaters, flashes, curtain/shadow, trauma, high myopia, prior tear/detachment, and cataract or retinal surgery.
Exam findings
- Dilated peripheral retinal exam is the key diagnostic step; B-scan is useful when the view is limited.
Management
- Retinal tear or detachment symptoms require urgent ophthalmic evaluation because prompt treatment protects vision.
Trusted references
Retinal Tear Retina and vitreous - Patient education + clinical checklist
Ask about sudden new floaters, flashes, curtain/shadow, trauma, high myopia, prior tear/detachment, and cataract or retinal surgery.
Key history
- Ask about sudden new floaters, flashes, curtain/shadow, trauma, high myopia, prior tear/detachment, and cataract or retinal surgery.
Exam findings
- Dilated peripheral retinal exam is the key diagnostic step; B-scan is useful when the view is limited.
Management
- Retinal tear or detachment symptoms require urgent ophthalmic evaluation because prompt treatment protects vision.
Trusted references
Retinoschisis Retina and vitreous - Patient education
Degenerative retinoschisis is often asymptomatic; ask about flashes, floaters, field defect, family history, and symptoms suggesting retinal detachment.
Key history
- Degenerative retinoschisis is often asymptomatic; ask about flashes, floaters, field defect, family history, and symptoms suggesting retinal detachment.
Exam findings
- Smooth dome-shaped peripheral retinal splitting, commonly inferotemporal, with an absolute scotoma supports degenerative retinoschisis.
- Differentiate schisis cavity from rhegmatogenous retinal detachment and note inner or outer wall breaks.
Management
- Most degenerative retinoschisis is observed because progression is uncommon; treatment is reserved for selected progressive schisis detachment or retinal detachment scenarios.
Trusted references
Roth Spot Retina and vitreous - Patient education
Ask about fever, chills, weight loss, fatigue, IV drug use, dental infection, valvular/prosthetic heart disease, immunosuppression, bleeding/bruising, anemia, hypertension, diabetes, HIV risk, pregnancy, and malignancy symptoms.
Key history
- Ask about fever, chills, weight loss, fatigue, IV drug use, dental infection, valvular/prosthetic heart disease, immunosuppression, bleeding/bruising, anemia, hypertension, diabetes, HIV risk, pregnancy, and malignancy symptoms.
Workup
- Roth spots are nonspecific; workup is directed by systemic concern, including endocarditis, hematologic disease, anemia, hypertensive or diabetic retinopathy, HIV, and other causes.
Management
- Treat the underlying systemic disease; ophthalmic treatment is usually not needed for the spot itself unless ocular complications are present.
Trusted references
Roth Spot Retina and vitreous - Clinical checklist
Ask about fever, chills, weight loss, fatigue, IV drug use, dental infection, valvular/prosthetic heart disease, immunosuppression, bleeding/bruising, anemia, hypertension, diabetes, HIV risk, pregnancy, and malignancy symptoms.
Key history
- Ask about fever, chills, weight loss, fatigue, IV drug use, dental infection, valvular/prosthetic heart disease, immunosuppression, bleeding/bruising, anemia, hypertension, diabetes, HIV risk, pregnancy, and malignancy symptoms.
Workup
- Roth spots are nonspecific; workup is directed by systemic concern, including endocarditis, hematologic disease, anemia, hypertensive or diabetic retinopathy, HIV, and other causes.
Management
- Treat the underlying systemic disease; ophthalmic treatment is usually not needed for the spot itself unless ocular complications are present.
Trusted references
Solar or Photic Retinopathy Retina and vitreous - Clinical checklist
Decreased visual acuity, central/paracentral scotomata
Key history
- Decreased visual acuity, central/paracentral scotomata
Management
- F/up retina 1 week for OCT
Trusted references
Subconjunctival Hemorrhage Retina and vitreous - Patient education + clinical checklist
Management
- No need to stop anticoagulation
Trusted references
Image example
Transient Monocular Vision Loss Retina and vitreous - Clinical checklist
Workup
- New neurologic deficits
- Concerning worsening symptoms provided to patient
Trusted references
Valsalva Retinopathy Retina and vitreous - Clinical checklist
Decreased vision after Valsalva maneuver (heavy lifting, coughing, vomiting, or straining during bowel movement)
Key history
- Decreased vision after Valsalva maneuver (heavy lifting, coughing, vomiting, or straining during bowel movement)
Follow up
- Retina 1 week for IVFA to rule out other causes including RAM or diabetic retinopathy
Trusted references
Vitreous Hemorrhage Retina and vitreous - Patient education + clinical checklist
Likely Diabetic retinopathy
Exam findings
- Likely Diabetic retinopathy
- Given DR finding in other eye. B scan with flat retina
- Given hx of flashes
- Floaters. B scan with flat retina
Management
- Precautions given: no heavy lifting, no bending, no straining
- Keep HOB elevated
- Avoid NSAIDs, ASA, and other anticoagulants as medically able
Follow up
- Retina within one week for management of likely PDR
- Retina in 1-2 days for reassessment for potential RRD once VH settles
Trusted references
Vitreous Syneresis Retina and vitreous - Patient education + clinical checklist
No flashes or dark curtain
Key history
- No flashes or dark curtain
Exam findings
- By signs and symptoms exam consistent with vitreous syneresis
- No PVD, shafer negative, no breaks or RD on 360 SDE
- No headache or eye pain to suggest alternative etiology
Trusted references
Anisocoria Neuro-ophthalmology - Patient education + clinical checklist
Finding of pupil asymmetry first noted
Key history
- Finding of pupil asymmetry first noted
- Denies hx of ocular trauma
- Denies hx of eye drops and ointments
- No hx of syphilis, IVDU, high risk sexual behavior
- Old photographs reviewed, unable to determine pupil size based on quality of photos
Exam findings
- Pupils round, no margin defects OU
- There is poor / good
- There is good / sluggish / poor / tonic
- See above re pupil measurements (light, dark, post-testing)
- Worse in light / dark
- Constriction occurs with 0.125% pilocarpine consistent with Adie tonic pupil
- There is a round pupil with poor near constriction
Trusted references
Cluster Headache Neuro-ophthalmology - Patient education + clinical checklist
Unilateral, very painful (stabbing), periorbital, frontal, or temporal headache associated with ipsilateral tearing, rhinorrhea, sweating, nasal stuffiness, and/or a droopy eyelid
Key history
- Unilateral, very painful (stabbing), periorbital, frontal, or temporal headache associated with ipsilateral tearing, rhinorrhea, sweating, nasal stuffiness, and/or a droopy eyelid
- Lasts for minutes to hours
- Recurring once or twice daily for several weeks, followed by a headache-free interval of months to years
- Precipitating factors of alcohol and nitroglycerin Exam-erythematous facial flush, ptosis, anisicoria, conjunctival injection Assessment By history and exam most consistent with cluster headache
- There is / is not
- There is / is
- Ddx migraine, Chronic paroxysmal hemicrania (several <30 secs attacks of pain and tearing, ocular injection, rhinorrhea), trigeminal autonomic cephalgia (burning/stabbing pain unilateral, periorbital
Trusted references
Fourth Cranial Nerve Palsy Neuro-ophthalmology - Patient education + clinical checklist
Isolated 4th nerve palsy, P/w
Key history
- Isolated 4th nerve palsy, P/w
- Symmetric pupils with symmetric constriction
- No V1/V2 hypoesthesia
- Stroke alert called and STAT CTA head/neck and CT head ordered
- Neurology consulted- GCA labs normal (ESR
Trusted references
Horner Syndrome Neuro-ophthalmology - Clinical checklist
Clarify onset, pain, trauma or surgery, neck/chest symptoms, headache, facial pain, anhidrosis, malignancy history, and pediatric systemic symptoms.
Key history
- Clarify onset, pain, trauma or surgery, neck/chest symptoms, headache, facial pain, anhidrosis, malignancy history, and pediatric systemic symptoms.
Exam findings
- Classic findings are ipsilateral ptosis, miosis, dilation lag, and possible anhidrosis; anisocoria is greater in the dark.
- Assess ocular motility, facial sensation, other cranial nerves, arm pain, and signs localizing to brainstem, cavernous sinus, neck, apex of lung, or carotid artery.
Workup
- New or painful Horner syndrome requires evaluation for an underlying lesion; acute painful Horner syndrome is concerning for carotid dissection.
Management
- Treatment is directed at the cause, with urgent neurologic or vascular evaluation when dissection, stroke, tumor, or trauma is suspected.
Trusted references
Migraine With Visual Aura Neuro-ophthalmology - Patient education + clinical checklist
Typical visual aura is gradual, reversible, often binocular, and commonly described as scintillating, zig-zag, fortification, crescent, scotoma, blur, or field disturbance.
Key history
- Typical visual aura is gradual, reversible, often binocular, and commonly described as scintillating, zig-zag, fortification, crescent, scotoma, blur, or field disturbance.
- Aura usually builds over minutes and resolves within about an hour; aura without headache can mimic TIA or seizure.
Exam findings
- A stable patient with typical migraine aura usually has a normal neurologic and ocular exam between episodes.
Workup
- Neuroimaging or vascular/inflammatory workup is guided by atypical features, abnormal exam, or vascular/GCA concern rather than routine typical aura.
Differential
- Red flags include monocular vision loss, fixed field loss, new neurologic deficit, sudden severe headache, onset after age 50, GCA symptoms, seizure features, or atypical/progressive duration.
Trusted references
Myasthenia Neuro-ophthalmology - Clinical checklist
Variable ptosis or diplopia that worsens with fatigue and improves with rest supports ocular myasthenia.
Key history
- Variable ptosis or diplopia that worsens with fatigue and improves with rest supports ocular myasthenia.
- Ask about bulbar, respiratory, limb, and generalized fatigable weakness.
Exam findings
- Look for fatigable ptosis, variable ocular misalignment, Cogan lid twitch, orbicularis weakness, and improvement after rest or ice-pack testing.
Workup
- Testing may include acetylcholine receptor antibodies, MuSK/LRP4 testing when appropriate, repetitive nerve stimulation, single-fiber EMG, and chest imaging for thymic disease based on clinical context.
Management
- Coordinate neurology care; urgent evaluation is required for bulbar or respiratory symptoms.
Trusted references
Non-Arteritic Anterior Ischemic Optic Neuropathy Neuro-ophthalmology - Patient education + clinical checklist
Classically acute painless monocular vision loss over hours to days, often noticed on awakening.
Key history
- Classically acute painless monocular vision loss over hours to days, often noticed on awakening.
- Ask about age over 50, sleep apnea, diabetes, hypertension, hyperlipidemia, nocturnal hypotension, phosphodiesterase-5 inhibitor use, optic disc drusen, and GCA symptoms.
Exam findings
- Findings include decreased acuity or field defect, dyschromatopsia, RAPD when asymmetric, swollen optic nerve, splinter hemorrhages, and crowded fellow disc.
Workup
- Rule out arteritic AION when age or symptoms suggest GCA; atypical features may require inflammatory, infectious, compressive, or demyelinating optic neuropathy workup.
Management
- Address vascular risk factors and sleep apnea; no treatment has proven reliable for reversing typical NAION vision loss.
Trusted references
Optic Nerve Edema / Disc Edema Neuro-ophthalmology - Patient education + clinical checklist
Ask about headache, transient visual obscurations, pulsatile tinnitus, diplopia, nausea/vomiting, positional symptoms, weight change, pregnancy, and medication triggers including tetracyclines, retinoids, lithium, and growth hormone.
Key history
- Ask about headache, transient visual obscurations, pulsatile tinnitus, diplopia, nausea/vomiting, positional symptoms, weight change, pregnancy, and medication triggers including tetracyclines, retinoids, lithium, and growth hormone.
Exam findings
- Track acuity, pupils/APD, color, motility/abduction deficit, visual fields, and disc edema grade; OCT RNFL/GCC and fundus photos help monitor change.
Workup
- True papilledema generally requires urgent neuroimaging before lumbar puncture and evaluation for secondary causes such as mass, venous sinus thrombosis, infection, medication, or malignant hypertension.
Trusted references
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Optic Neuritis Neuro-ophthalmology - Patient education
Typical demyelinating optic neuritis causes acute unilateral vision loss that worsens over days, eye pain with movement, washed-out color vision, and sometimes photopsias or Uhthoff phenomenon.
Key history
- Typical demyelinating optic neuritis causes acute unilateral vision loss that worsens over days, eye pain with movement, washed-out color vision, and sometimes photopsias or Uhthoff phenomenon.
Exam findings
- Check acuity, color/contrast, pupils for RAPD, visual fields, ocular motility, optic nerve appearance, and retinal/vitreous inflammation.
- The optic disc may look normal in typical retrobulbar optic neuritis; disc edema occurs in a minority.
Workup
- MRI brain and orbits with contrast helps confirm optic nerve enhancement and assess demyelinating lesions; atypical features should prompt broader inflammatory, infectious, infiltrative, or antibody-mediated workup.
Management
- Steroids may speed early recovery in selected typical cases but do not guarantee final visual outcome; management should be coordinated with neuro-ophthalmology or neurology.
Trusted references
Optic Neuritis, without demyelinating lesions in brain Neuro-ophthalmology - Clinical checklist
Typical demyelinating optic neuritis causes acute unilateral vision loss that worsens over days, eye pain with movement, washed-out color vision, and sometimes photopsias or Uhthoff phenomenon.
Key history
- Typical demyelinating optic neuritis causes acute unilateral vision loss that worsens over days, eye pain with movement, washed-out color vision, and sometimes photopsias or Uhthoff phenomenon.
Exam findings
- Check acuity, color/contrast, pupils for RAPD, visual fields, ocular motility, optic nerve appearance, and retinal/vitreous inflammation.
- The optic disc may look normal in typical retrobulbar optic neuritis; disc edema occurs in a minority.
Workup
- MRI brain and orbits with contrast helps confirm optic nerve enhancement and assess demyelinating lesions; atypical features should prompt broader inflammatory, infectious, infiltrative, or antibody-mediated workup.
Management
- Steroids may speed early recovery in selected typical cases but do not guarantee final visual outcome; management should be coordinated with neuro-ophthalmology or neurology.
Trusted references
Optic Neuropathy Neuro-ophthalmology - Clinical checklist
OUPainless, progressive, bilateral loss of vision over
Key history
- OUPainless, progressive, bilateral loss of vision over
Management
- Strict return precautions of vision loss, new neurologic deficits, new diplopia, fevers, chills, or concerning worsening symptoms provided to patient
Trusted references
Parinaud Oculoglandular Conjunctivitis Neuro-ophthalmology - Clinical checklist
Diplopia, blurred vision, difficulty looking up, headache, nausea/vomiting, pineal/midbrain symptoms, hydrocephalus symptoms, or neurologic deficits are relevant.
Key history
- Diplopia, blurred vision, difficulty looking up, headache, nausea/vomiting, pineal/midbrain symptoms, hydrocephalus symptoms, or neurologic deficits are relevant.
Workup
- MRI brain is used to evaluate pineal, midbrain, hydrocephalus, vascular, demyelinating, or mass lesions.
Management
- Management depends on the underlying neurologic cause and should be coordinated urgently when hydrocephalus, mass, or acute neurologic findings are suspected.
Trusted references
Parinaud Syndrome Neuro-ophthalmology - Clinical checklist
Diplopia, blurred vision, difficulty looking up, headache, nausea/vomiting, pineal/midbrain symptoms, hydrocephalus symptoms, or neurologic deficits are relevant.
Key history
- Diplopia, blurred vision, difficulty looking up, headache, nausea/vomiting, pineal/midbrain symptoms, hydrocephalus symptoms, or neurologic deficits are relevant.
Workup
- MRI brain is used to evaluate pineal, midbrain, hydrocephalus, vascular, demyelinating, or mass lesions.
Management
- Management depends on the underlying neurologic cause and should be coordinated urgently when hydrocephalus, mass, or acute neurologic findings are suspected.
Trusted references
Seventh Cranial Nerve Palsy Neuro-ophthalmology - Clinical checklist
Ask about onset, progression, complete versus incomplete weakness, pain, rash or vesicles, tick exposure, fever, trauma, surgery, malignancy, hearing loss, vertigo, taste change, and other neurologic deficits.
Key history
- Ask about onset, progression, complete versus incomplete weakness, pain, rash or vesicles, tick exposure, fever, trauma, surgery, malignancy, hearing loss, vertigo, taste change, and other neurologic deficits.
Exam findings
- Grade facial weakness and distinguish upper motor neuron from lower motor neuron pattern by forehead involvement.
- Document lagophthalmos, blink, Bell phenomenon, corneal sensation, exposure keratopathy, epithelial defect, ulceration, ectropion, punctal malposition, and CN5/CN8 findings.
Management
- Protect the ocular surface with lubrication, moisture chamber or taping, and escalation for exposure keratopathy; procedural eyelid support may be needed when recovery is poor.
Trusted references
Sixth Cranial Nerve Palsy Neuro-ophthalmology - Patient education + clinical checklist
Isolated 6th nerve palsy, P/w
Key history
- Isolated 6th nerve palsy, P/w
- No V1/V2 hypoesthesia- Exam with esotropia and abduction deficit,
- Remainder of SL exam and DFE unremarkable, no papilledema
Exam findings
- CN6 palsy, likely ischemic given patient history and unremarkable neuro-imaging
Trusted references
Third Cranial Nerve Palsy Neuro-ophthalmology - Patient education + clinical checklist
Isolated pupil-involving/sparing complete/partial 3rd nerve palsy, P/w
Key history
- Isolated pupil-involving/sparing complete/partial 3rd nerve palsy, P/w
- No APD by reverse
- No V1/V2 hypoesthesia- Fixed
- Poorly reactive pupil
- Ptosis w/ MRD1
Exam findings
- CN3 palsy, likely ischemic given patient history and unremarkable neuro-imaging
Trusted references
Visual disturbance Neuro-ophthalmology - Clinical checklist
Follow up
- Neuro-ophth 8 weeks
Trusted references
Anatomic Narrow Angles Glaucoma and optic nerve - Patient education
Anatomic narrow angles are often asymptomatic; intermittent blur, halos, brow ache, headache, eye pain, nausea, or vomiting suggests intermittent or acute angle closure.
Key history
- Anatomic narrow angles are often asymptomatic; intermittent blur, halos, brow ache, headache, eye pain, nausea, or vomiting suggests intermittent or acute angle closure.
Exam findings
- Gonioscopy is the key test; document angle width, iridotrabecular contact, peripheral anterior synechiae, IOP, optic nerve, and visual field status.
Trusted references
Glaucoma Glaucoma and optic nerve - Patient education
Is a group of eye diseases that damage the optic nerve, which carries visual information from the eye to the brain
Key history
- Is a group of eye diseases that damage the optic nerve, which carries visual information from the eye to the brain
- This damage is often associated with elevated pressure inside the eye, although glaucoma can also occur when eye pressure is within the usual range.Glaucoma typically affects peripheral, or side, vision first
- Most people do not notice symptoms during the early stages because central vision may remain clear
- Without treatment, the area of vision loss can gradually expand and may eventually affect central vision
- Vision already lost from glaucoma is usually permanent, but
Management
- Can slow or prevent further damage.Treatment- Your doctor has lowered your eye pressure with medication and has prescribed you eye drops and/or oral medication to continue taking at home
- It is VERY important that you continue taking these medications
- Otherwise your eye pressure may increase again
- An updated medication list to each appointment.Monitoring Glaucoma is usually a lifelong condition requiring regular follow-up
- Your eye doctor may monitor the eye pressure, examine the optic nerve, photograph or scan the nerve, and test your peripheral vision
- Keep every appointment even when your eyes feel normal, since worsening glaucoma often causes no early symptoms.Tell your family members about your diagnosis
- Parents, siblings, and children may have an increased risk and should receive regular comprehensive eye examinations.General health and safety Most glaucoma is painless and does not cause sudden symptoms
Follow up
- In the time frame specified by your doctor
- It is essential to have your eye pressure checked again
- Do not stop or change the drops unless your eye doctor instructs you to do so
- If you use more than one eye drop, wait approximately 5 minutes between medications
- After placing a drop in the eye, gently close the eye and press a finger against the inner corner near the nose for 1-2 minutes
- This may reduce medication absorption into the rest of the body
- Tell your eye doctor if you have difficulty obtaining, remembering, or administering your drops
Trusted references
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Glaucoma Suspect Glaucoma and optic nerve - Patient education + clinical checklist
No personal or familial POAG hx
Key history
- No personal or familial POAG hx
Exam findings
- Increased C/D; healthy neuroretinal rim, (-) notch/heme
Trusted references
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Hypotony Glaucoma and optic nerve - Clinical checklist
Denies pain, reduced vision- Denies recent ocular surgery or trauma, history of renal disease, diabetes, or myotonic dystrophy
Key history
- Denies pain, reduced vision- Denies recent ocular surgery or trauma, history of renal disease, diabetes, or myotonic dystrophy
Exam findings
- Vision is good, the anterior chamber is well formed, and there is no wound leak, retinal detachment, or kissing choroidal detachments, then the low IOP poses no immediate problem
Trusted references
POAG(s), AACG, uveitic glaucoma, neovascular glaucoma Glaucoma and optic nerve - Clinical checklist
No family history
Key history
- No family history
- Hypertension- No previous history of increased IOP
- Chronic steroid use
- Ocular trauma- Med considerations: No asthma
- Heart block or bradyarrhythmia
Exam findings
- SLE: MCE, stromal edema, AC deep and quiet,
Management
- Cases involving large ciliochoroidal or choroidal effusions may benefit from intravenous corticosteroids, as inflammation may play a role in their formation
Follow up
- Glaucoma clinic 1-2 days for IOP check and further management
- Do not use CAIs Treat with cycloplegia to induce posterior rotation of the ciliary body (e.g
- Prednisolone 1% q.i.d.)
- Consider hospitalization and
Trusted references
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Canaliculitis Trauma, orbit, and oculoplastics - Clinical checklist
Workup
- Smears and cultures of the material expressed from the punctum, including slides for Gram stain and Giemsa stain
- Thioglycolate and Sabouraud cultures sent
Follow up
- In oculoplastics for consideration of canaliculotomy for complete removal of a retained punctal plug if necessary
Trusted references
Chemical Conjunctivitis / Chemical Eye Injury Trauma, orbit, and oculoplastics - Patient education + clinical checklist
Chemical conjunctivitis,
Key history
- Chemical conjunctivitis,
- LLL.0 BUL
- BLL- No phenylephrine or brimonidine used to prevent vasoconstriction
Exam findings
- No limbal whitening or conjunctival blanching- No conjunctival or corneal epithelial defects and ulcerations as noted above
Follow up
- In cornea in 1 day to monitor improvement and assessment of conjunctival adhesions
Trusted references
Chemical Conjunctivitis without Ocular Sequelae Trauma, orbit, and oculoplastics - Clinical checklist
Conjunctival Laceration Trauma, orbit, and oculoplastics - Patient education + clinical checklist
IOP wnl, conjunctival injection, seidel negative,
Exam findings
- IOP wnl, conjunctival injection, seidel negative,
- No evidence of globe rupture or IOFB on examination
- No signs of bare sclera or tenons visible
Trusted references
Dacryoadenitis Trauma, orbit, and oculoplastics - Patient education + clinical checklist
Persistent or progressive swelling of the outer one-third of the upper eyelid
Key history
- Persistent or progressive swelling of the outer one-third of the upper eyelid
- Pain, no double vision
- No malaise, fevers/chills
- No rash, recent viral illness
- CT orbits with: pending
- CBC, CMP, quant TB, TSH, anti
- TSH, anti
Follow up
- Oculoplastics in 5-7 days
Trusted references
Dacryocystitis Trauma, orbit, and oculoplastics - Patient education + clinical checklist
Pain, erythema, edema over the medial canthus/lacrimal sac, tearing, purulent reflux, fever, and history of nasolacrimal duct obstruction support dacryocystitis.
Key history
- Pain, erythema, edema over the medial canthus/lacrimal sac, tearing, purulent reflux, fever, and history of nasolacrimal duct obstruction support dacryocystitis.
Exam findings
- Focal inferomedial lacrimal sac swelling with possible purulent punctal reflux is typical; pain with eye movements, proptosis, or diffuse orbital signs should prompt concern for orbital cellulitis or another diagnosis.
Management
- Acute dacryocystitis requires antimicrobial treatment and ophthalmology follow-up; definitive management often addresses the underlying nasolacrimal obstruction after infection is controlled.
Trusted references
Eyelid Contact Dermatitis Trauma, orbit, and oculoplastics - Patient education + clinical checklist
Contact Dermatitis, Sudden onset of periorbital rash, eyelid swelling, +pruritus
Key history
- Contact Dermatitis, Sudden onset of periorbital rash, eyelid swelling, +pruritus
- Watery discharge, skin crusting
Exam findings
- Periorbital edema, erythema, microvesicles, skin lichenification
Trusted references
Eyelid Laceration Trauma, orbit, and oculoplastics - Patient education
You had a cut involving your eyelid that required careful examination and repair
Key history
- You had a cut involving your eyelid that required careful examination and repair
- Because the eyelids protect the eye and contain structures important for blinking and tear drainage, proper wound care and
Follow up
- Are important for healing.Your eyelid was repaired with absorbable sutures
- These sutures usually loosen and dissolve on their own and do not routinely need to be removed
- Do not pull, trim, or attempt to remove them yourself
- Occasionally, a remaining suture may need to be removed by your doctor if it causes irritation or does not dissolve as expected.Wound care Apply the prescribed antibiotic ointment over the sutures exactly as directed
- Wash your hands before and after applying it
- Keep the wound clean and dry for the first 24-48 hours, unless instructed otherwise
- You may shower after 1-2 days
Trusted references
Floppy Eyelid Syndrome Trauma, orbit, and oculoplastics - Patient education + clinical checklist
Lid laxity found on exam; patient reports snoring, AM headaches, fatigue
Key history
- Lid laxity found on exam; patient reports snoring, AM headaches, fatigue
Follow up
- Risks of untreated sleep apnea explained to patient
Trusted references
Open Globe / Globe Rupture Trauma, orbit, and oculoplastics - Clinical checklist
Management
- Will admit patient to eye clinic with plans for globe exploration and RGR in OR.- John Kimmel and surgical senior aware
Trusted references
Glue (cyanoacrylate) ocular injury Trauma, orbit, and oculoplastics - Clinical checklist
Presents after glue to eye injury
Key history
- Presents after glue to eye injury
Exam findings
- Hardened glue present on lids, lashes, conj, cornea
- Epi defect present
- Glue injury to eye,
- Copious irrigation with warm normal saline, warm compresses, and ointment used to loosen hardened glue
Follow up
- Eye clinic Cornea 1 day
Trusted references
Glue (cyanoacrylate) ocular injury Trauma, orbit, and oculoplastics - Patient education
You accidentally got superglue in your eye, which can cause irritation, pain, and the eyelids or lashes to stick together
Key history
- You accidentally got superglue in your eye, which can cause irritation, pain, and the eyelids or lashes to stick together
- The eye was carefully cleaned, and you may need drops or ointment to help it heal
- Don't rub your eye.You can use warm compresses on your eyelids four times a day
Trusted references
Hyphema Trauma, orbit, and oculoplastics - Clinical checklist
Most hyphemas follow blunt trauma; ask about sickle cell disease/trait, anticoagulants, bleeding disorders, and prior ocular surgery.
Key history
- Most hyphemas follow blunt trauma; ask about sickle cell disease/trait, anticoagulants, bleeding disorders, and prior ocular surgery.
Exam findings
- Grade the anterior chamber blood and check IOP after open globe is excluded.
Management
- Use shield and activity restriction; monitor closely for rebleeding and IOP elevation.
Trusted references
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Idiopathic orbital inflammatory syndrome Trauma, orbit, and oculoplastics - Clinical checklist
Abrupt painful orbital symptoms, proptosis, swelling, erythema, diplopia, recurrent episodes, and absence of clear infection support idiopathic orbital inflammation after exclusion of mimics.
Key history
- Abrupt painful orbital symptoms, proptosis, swelling, erythema, diplopia, recurrent episodes, and absence of clear infection support idiopathic orbital inflammation after exclusion of mimics.
Exam findings
- Assess proptosis, eyelid edema, chemosis, EOM restriction, ptosis, decreased vision, optic nerve involvement, uveitis, and disc edema.
Workup
- Workup should exclude orbital cellulitis, thyroid eye disease, malignancy, vasculitis, sarcoidosis, IgG4-related disease, and other inflammatory or infectious causes.
Trusted references
IOFB Trauma, orbit, and oculoplastics - Clinical checklist
Look for open-globe signs, entry wound, Seidel positivity, peaked pupil, hyphema, lens violation, vitreous hemorrhage, retinal tear/detachment, and visible foreign body when safe.
Exam findings
- Look for open-globe signs, entry wound, Seidel positivity, peaked pupil, hyphema, lens violation, vitreous hemorrhage, retinal tear/detachment, and visible foreign body when safe.
Workup
- CT orbit is the preferred initial imaging test for most suspected IOFB; avoid MRI until metallic foreign body is definitively excluded.
Management
- Protect the globe, avoid pressure and scleral depression when the wound is not secure, and coordinate urgent surgical management.
Trusted references
Eyelid Laceration Trauma, orbit, and oculoplastics - Clinical checklist
Canalicular involvement- Association with ocular or deep adnexal trauma that requires surgery (e.g
Exam findings
- Canalicular involvement- Association with ocular or deep adnexal trauma that requires surgery (e.g
- Indicating penetration of the orbital septum
- All such patients require CT imaging and careful documentation of levator and extraocular muscle (EOM) function
Trusted references
Orbital Cellulitis Trauma, orbit, and oculoplastics - Patient education + clinical checklist
Painful red swollen eyelids with fever, sinus symptoms, headache, double vision, lethargy, or recent upper respiratory infection raises concern for orbital cellulitis.
Key history
- Painful red swollen eyelids with fever, sinus symptoms, headache, double vision, lethargy, or recent upper respiratory infection raises concern for orbital cellulitis.
Exam findings
- Proptosis, chemosis, pain with eye movements, ophthalmoplegia, decreased vision, APD, elevated IOP, optic nerve involvement, fever, or leukocytosis suggests orbital rather than preseptal disease.
Workup
- CT orbit/sinuses helps distinguish preseptal from orbital cellulitis and identify sinusitis, abscess, intracranial extension, or other complications.
Management
- Orbital cellulitis generally requires hospital admission, broad-spectrum IV antibiotics, close ophthalmology/ENT monitoring, and drainage when abscess or clinical deterioration requires it.
Trusted references
Orbital Fracture Trauma, orbit, and oculoplastics - Patient education
Blunt orbital trauma with diplopia, pain on eye movement, numb cheek or upper lip, nausea/bradycardia with gaze, epistaxis, or vision symptoms suggests orbital fracture or entrapment.
Key history
- Blunt orbital trauma with diplopia, pain on eye movement, numb cheek or upper lip, nausea/bradycardia with gaze, epistaxis, or vision symptoms suggests orbital fracture or entrapment.
Exam findings
- Assess visual acuity, pupils/APD, motility, diplopia field, V2 sensation, enophthalmos, globe injury, hyphema, retinal injury, and oculocardiac reflex.
Workup
- Thin-cut CT orbit with coronal reconstructions is the usual imaging test when fracture is suspected.
Management
- Avoid nose blowing; urgent repair is considered for entrapment, oculocardiac reflex, marked motility restriction, early significant enophthalmos, or large fractures with expected late enophthalmos.
Trusted references
Preseptal Cellulitis Trauma, orbit, and oculoplastics - Patient education + clinical checklist
Eyelid swelling, erythema, warmth, tenderness, fever, trauma, insect bite, sinusitis, chalazion, dacryocystitis, or skin infection support preseptal cellulitis.
Key history
- Eyelid swelling, erythema, warmth, tenderness, fever, trauma, insect bite, sinusitis, chalazion, dacryocystitis, or skin infection support preseptal cellulitis.
Exam findings
- Normal vision, pupils, color, ocular motility, and absence of proptosis favor preseptal disease; pain with eye movements, ophthalmoplegia, chemosis, APD, decreased vision, or proptosis suggests orbital cellulitis.
Workup
- CT orbit/sinuses is indicated when severe swelling prevents exam, orbital signs are present, there is poor response, or complications are suspected.
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Ptosis Trauma, orbit, and oculoplastics - Patient education + clinical checklist
Drooping upper eyelid, superior visual field compromise.- Denies diplopia, headache, and neck pain
Key history
- Drooping upper eyelid, superior visual field compromise.- Denies diplopia, headache, and neck pain
- Denies dysphagia, dysarthria, dyspnea
- Review of old photographs revealed
- Denies hx of ocular surgery
- Does not wear CL
- Denies frequent eye rubbing
Exam findings
- OD / OS, see measurements above (MRD1, LF). PERRL, no rAPD
- No proptosis (herthel above)
- No mass or stepoff on orbital rim palpation
- Lid flip wnl
- Often gets worse in downgaze
- Levator stretching or dehiscence can result from normal aging, repetitive eye rubbing, use of rigid contact lenses (pulling on the eyelids to put in or take out), trauma, or previous intraocular surgery (speculum-related muscle damage)
- Third CN palsy (often complete ptosis
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Right/Left orbital wall/floor/roof fracture, Orbital Floor Fracture Trauma, orbit, and oculoplastics - Clinical checklist
Blunt orbital trauma with diplopia, pain on eye movement, numb cheek or upper lip, nausea/bradycardia with gaze, epistaxis, or vision symptoms suggests orbital fracture or entrapment.
Key history
- Blunt orbital trauma with diplopia, pain on eye movement, numb cheek or upper lip, nausea/bradycardia with gaze, epistaxis, or vision symptoms suggests orbital fracture or entrapment.
Exam findings
- Assess visual acuity, pupils/APD, motility, diplopia field, V2 sensation, enophthalmos, globe injury, hyphema, retinal injury, and oculocardiac reflex.
Workup
- Thin-cut CT orbit with coronal reconstructions is the usual imaging test when fracture is suspected.
Management
- Avoid nose blowing; urgent repair is considered for entrapment, oculocardiac reflex, marked motility restriction, early significant enophthalmos, or large fractures with expected late enophthalmos.
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Traumatic Hyphema Trauma, orbit, and oculoplastics - Clinical checklist
Most hyphemas follow blunt trauma; ask about sickle cell disease/trait, anticoagulants, bleeding disorders, and prior ocular surgery.
Key history
- Most hyphemas follow blunt trauma; ask about sickle cell disease/trait, anticoagulants, bleeding disorders, and prior ocular surgery.
Exam findings
- Grade the anterior chamber blood and check IOP after open globe is excluded.
Management
- Use shield and activity restriction; monitor closely for rebleeding and IOP elevation.
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Traumatic Microhyphema Trauma, orbit, and oculoplastics - Clinical checklist
Most hyphemas follow blunt trauma; ask about sickle cell disease/trait, anticoagulants, bleeding disorders, and prior ocular surgery.
Key history
- Most hyphemas follow blunt trauma; ask about sickle cell disease/trait, anticoagulants, bleeding disorders, and prior ocular surgery.
Exam findings
- Grade the anterior chamber blood and check IOP after open globe is excluded.
Management
- Use shield and activity restriction; monitor closely for rebleeding and IOP elevation.
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Accommodative Spasm Lens, refraction, and general - Patient education + clinical checklist
Bilateral blurred distance vision, fluctuating vision, blurred vision when shifting gaze from near to far, headache, and eye strain while reading
Key history
- Bilateral blurred distance vision, fluctuating vision, blurred vision when shifting gaze from near to far, headache, and eye strain while reading
- Endorses recent life stressors, fatigue
- Reports recent episodes of prolonged reading/screen time provoking symptoms
Exam findings
- By history and exam, presentation most consistent with accommodative spasm
- Age (teenage), recent stress, prolonged near work all consistent with diagnosis
Differential
- Uncorrected hyperopia. causes of pseudomyopia considered on ddx, there is no hyperglycemia, no reports of sulfa or anticholinesterase medications), and there is no anterior displacement of the lens-iris diaphragm
- Plan- Reduced stressors as able
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Cataract Lens, refraction, and general - Patient education + clinical checklist
Complains of progressive decrease in visual acuity, difficulty with glare and bright lights
Key history
- Complains of progressive decrease in visual acuity, difficulty with glare and bright lights
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Convergence Insufficiency Lens, refraction, and general - Patient education + clinical checklist
Eye discomfort and blurred vision from reading or near work
Key history
- Eye discomfort and blurred vision from reading or near work
Exam findings
- Full EOMs, orthotropic at near and distance by cover-uncover testing. exophoria at near, near point of convergence (point of double vision) found to be
- At reading distance, patient notes double vision (break point) at
- Near point of convergence noted to be
- Fusional ability break point and recovery point. A 4 PD base in prism at reading distance improves clarity
- Together, these testing are all consistent with convergence insufficiency. there is no convergence paralysis
- No accommodative insufficiency as base in prism would reduce clarity in this condition
- Ddx also includes refractive error
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Lens Subluxation / Dislocation Lens, refraction, and general - Patient education + clinical checklist
Hx of cataract surgery in
Key history
- Hx of cataract surgery in
- Clear cornea, AC deep and quiet, IOP wnl
- No retinal detachment or breaks on DFEAssessmentIOL subluxation OD / OS
- Provoking factors included
- Trauma: Most common
- Increased risk of retinal detachment -Homocystinuria: Bilateral lens subluxation, classically inferonasally
- Increased risk of retinal detachment
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Presbyopia Lens, refraction, and general - Patient education + clinical checklist
Reports progressive difficulty with near work
Key history
- Reports progressive difficulty with near work
- Notes distance vision is unaffected
- Finds themselves holding phones, menus, reading material further from face Exam Distance BCVA: OD OSNear BCVA at 14 inches: OD OSAssessment By exam and history, patients visual issue is presbyopia
- Advised on etiology and
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Reassuring Eye Examination Lens, refraction, and general - Patient education
Your exam today was reassuring and without immediately vision threatening findings
Key history
- Your exam today was reassuring and without immediately vision threatening findings
- We recommend you
Follow up
- For a complete evaluation
- If you have any new changes to your vision including persistent flashes of light, numerous new floaters, a curtain across the vision, pain with eye movement, double vision, or worsening blurry vision
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Refractive Error Lens, refraction, and general - Patient education
Blur at distance, near, or both that improves with pinhole supports refractive error.
Key history
- Blur at distance, near, or both that improves with pinhole supports refractive error.
Exam findings
- Refraction determines the lens prescription; otherwise normal ocular exam supports uncomplicated refractive blur.
Differential
- Do not attribute decreased vision to refractive error when pinhole does not improve vision or when pain, photophobia, neurologic symptoms, media opacity, retinal disease, or optic neuropathy signs are present.
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Secondary Cataract Lens, refraction, and general - Clinical checklist
History of CEIOL, gradual blurry/cloudy vision after cataract surgery, glare, halos, contrast, trouble w/ night driving or bright lights
Key history
- History of CEIOL, gradual blurry/cloudy vision after cataract surgery, glare, halos, contrast, trouble w/ night driving or bright lights
Exam findings
- + PCO without retained cortical material
Follow up
- Explained to patient to return to ER if worsening symptoms
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Visual Loss Lens, refraction, and general - Clinical checklist
Loss of vision OU
Key history
- Loss of vision OU
- No precipitating event or trauma
Exam findings
- Otherwise normal ocular exam as documented above, normal pupillary light reaction OU, no rAPD
- Optokinetic testing of the symptomatic eye revealed physiologic nystagmus
- Base out prism (6 PD) testing revealed inward shift of the prism-covered eye
- Based down prism (4 PD) placed in front of better seeing eye, patient reports seeing 2 images
- Reported vision loss, symptom onset
- There are no ocular findings to suggest the degree of vision loss on visual acuity testing
- Pupillary response normal suggesting anterior visual pathway intact
Differential
- Amblyopia, cortical blindness, retinal dystrophy/retinopathy, nonphysiologic visual loss
- Requires further ophthalmic testing outpatient including OCT macula, OCT nerve
Follow up
- U: Unilateral visual lossB: Bilateral visual loss Patients Claiming No Light Perception Determine each pupil's reaction to light (U or B): The presence of a normal pupillary reaction suggests that anterior visual pathways are intact
- But does not prove nonphysiologic visual loss (pupillary response is maintained in cortical blindness)
- When only one eye has no light perception, that pupil will not react to light
- The pupil should not appear dilated unless the patient has bilateral lack of light perception or third cranial nerve involvement
- A defect should be present in unilateral or asymmetric visual loss to this degree.2.Mirror test (U or B): Cover the better-seeing eye if monocular visual loss
- Slowly tilt a large mirror from side to side in front of the patient's eyes, holding it beyond their range of hand motion vision
- If the eyes move in the same direction of the mirror, the patient can see better than hand motion.3.Optokinetic test (U or B): Cover the better-seeing eye if monocular visual loss
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Reassuring Eye Examination Lens, refraction, and general - Patient education
You had a thorough eye exam which revealed that both your eyes were healthy
Key history
- You had a thorough eye exam which revealed that both your eyes were healthy
- Available testing here did not reveal any cause for your vision loss, so we would like to test your vision again in our outpatient ophthalmology clinic using tools that can provide more detail about the nature of your vision changes
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Aberrant Regeneration of the Third Nerve Systemic and consult topics - Patient education + clinical checklist
History of acquired third-nerve palsy, trauma, aneurysm, cavernous sinus disease, compressive lesion, or prior neuroimaging is key.
Key history
- History of acquired third-nerve palsy, trauma, aneurysm, cavernous sinus disease, compressive lesion, or prior neuroimaging is key.
Exam findings
- Look for synkinetic lid, pupil, and ocular motility findings such as lid elevation on adduction or downgaze, pupillary constriction with attempted eye movement, ptosis, and residual motility deficits.
Workup
- Aberrant regeneration after a presumed ischemic third-nerve palsy should prompt concern for prior or ongoing compressive pathology if imaging has not already excluded it.
Management
- Coordinate neuro-ophthalmology care; treatment is directed at the cause and residual diplopia, ptosis, or exposure symptoms.
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Adies Pupil Systemic and consult topics - Clinical checklist
Incidental anisocoria, photophobia, difficulty with near focus, blur during accommodation shifts, trauma, infection, diabetes, neurologic symptoms, or syphilis risk are useful history points.
Key history
- Incidental anisocoria, photophobia, difficulty with near focus, blur during accommodation shifts, trauma, infection, diabetes, neurologic symptoms, or syphilis risk are useful history points.
Exam findings
- Adie tonic pupil has poor light reaction with better near constriction, tonic slow redilation, light-near dissociation, and sectoral iris sphincter palsy or vermiform movements.
- Anisocoria is usually greater in light when the larger pupil is abnormal.
Workup
- Dilute pilocarpine supersensitivity can support postganglionic parasympathetic denervation but is not perfectly specific; workup is guided by atypical, bilateral, neurologic, infectious, or traumatic features.
Management
- Most idiopathic Adie pupils are benign and need reassurance; symptomatic photophobia or accommodative difficulty can be managed selectively.
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Angioid Streaks Systemic and consult topics - Clinical checklist
No high myopia
Key history
- No high myopia
Exam findings
- No CNV or SRF.- Mottled fundus appearance with an orange hue (peau d'orange)
- Although ROS negative, fifty percent of cases are associated with systemic diseases so will send workup
Workup
- Serum alkaline phosphatase and urine calcium levels- Sickle cell preparation and hemoglobin electrophoresis given patient is of African descent
Follow up
- Return immediately if changes are noted- Discussed case with dermatology team, plan for Dermatology
- In next 2-4 weeks for skin or scar biopsy given PXE is suspected
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Arteriovenous fistula (AVF) Systemic and consult topics - Clinical checklist
High-flow fistulas have an abrupt onset, often following trauma or rupture of an intracavernous aneurysm
Exam findings
- High-flow fistulas have an abrupt onset, often following trauma or rupture of an intracavernous aneurysm
- Low-flow fistulas have a more insidious presentation, most commonly in hypertensive women >50 years of age, and are due to dural arteriovenous malformations (AVMs)
Workup
- Reversed, arterialized flow in the superior ophthalmic vein is detectable on imaging
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Blebitis Systemic and consult topics - Clinical checklist
Red eye, aching pain, photophobia, decreased vision, and mucous discharge.- Hx trabeculectomy in
Key history
- Red eye, aching pain, photophobia, decreased vision, and mucous discharge.- Hx trabeculectomy in
- CVF full- No bleb leak by Seidel test (neg)(Grade 1): Bleb appears milky with loss of translucency
- Microhypopyon in loculations of the bleb
- Frank purulent material in and leaking from the bleb
- Intense conjunctival injection. IOP is
Exam findings
- Hyperemia or purulence
- But no anterior chamber or vitreous involvement.Grade 2 (moderate): Bleb infection with anterior chamber inflammation but no vitreous involvement.Grade 3 (severe): Bleb infection with anterior chamber and vitreous involvement
Workup
- Culture of bleb or anterior chamber tap performed given grade 2 blebitis
Management
- Same approach as mild blebitis
- More careful monitoring
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Blind Painful Eye Systemic and consult topics - Patient education
Phthisical eyes may be soft, shrunken, disorganized, scarred, opaque, thickened, or cosmetically altered; exclude treatable inflammation, infection, malignancy, and pressure-related pain.
Exam findings
- Phthisical eyes may be soft, shrunken, disorganized, scarred, opaque, thickened, or cosmetically altered; exclude treatable inflammation, infection, malignancy, and pressure-related pain.
Management
- Primary goal is comfort and cosmesis, starting with medical pain control when appropriate and escalating to cyclodestructive, injection, evisceration, or enucleation discussions when pain persists.
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Broken suture Systemic and consult topics - Clinical checklist
Noted to have loose suture at
Exam findings
- Noted to have loose suture at
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Endophthalmitis Systemic and consult topics - Patient education + clinical checklist
Sudden onset of decreased vision and increasing eye pain after surgical procedure
Key history
- Sudden onset of decreased vision and increasing eye pain after surgical procedure
Follow up
- In retina tomorrow
Trusted references
Foreign-Body Sensation Systemic and consult topics - Patient education + clinical checklist
Exam and history as above
Key history
- Exam and history as above
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Hemifacial Spasm Systemic and consult topics - Clinical checklist
Unilateral contractures of the entire side of the face that do not disappear during sleep.- No prior CN VII palsy, injury at the level of the brainstem, or cancer history or lesion w/ compression of CN VII by a blood vessel or tumor
Key history
- Unilateral contractures of the entire side of the face that do not disappear during sleep.- No prior CN VII palsy, injury at the level of the brainstem, or cancer history or lesion w/ compression of CN VII by a blood vessel or tumor
Workup
- MRI brain with attention to the posterior fossa and path of CN VII
- MRI brain to rule out acoustic neuroma and NSGY/Neurology
Follow up
- In 1-2 weeks
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Herpes Zoster Ophthalmicus Systemic and consult topics - Clinical checklist
Painful unilateral V1 dermatomal rash, prodrome, eye pain, tearing, redness, decreased vision, immunosuppression, and age-related risk support HZO.
Key history
- Painful unilateral V1 dermatomal rash, prodrome, eye pain, tearing, redness, decreased vision, immunosuppression, and age-related risk support HZO.
Exam findings
- Inspect eyelids, scalp, and nose for vesicles or Hutchinson sign; assess corneal sensation, fluorescein staining, keratitis, uveitis, IOP, and posterior segment involvement.
Management
- Prompt systemic antiviral therapy and ophthalmology follow-up are important when HZO is suspected, especially with ocular symptoms or Hutchinson sign.
- Topical steroid decisions depend on ocular inflammation pattern and should be directed by ophthalmology.
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Herpes Zoster Ophthalmicus (Shingles Affecting the Eye) Systemic and consult topics - Patient education
Painful unilateral V1 dermatomal rash, prodrome, eye pain, tearing, redness, decreased vision, immunosuppression, and age-related risk support HZO.
Key history
- Painful unilateral V1 dermatomal rash, prodrome, eye pain, tearing, redness, decreased vision, immunosuppression, and age-related risk support HZO.
Exam findings
- Inspect eyelids, scalp, and nose for vesicles or Hutchinson sign; assess corneal sensation, fluorescein staining, keratitis, uveitis, IOP, and posterior segment involvement.
Management
- Prompt systemic antiviral therapy and ophthalmology follow-up are important when HZO is suspected, especially with ocular symptoms or Hutchinson sign.
- Topical steroid decisions depend on ocular inflammation pattern and should be directed by ophthalmology.
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Hypertension Systemic and consult topics - Patient education + clinical checklist
Workup
- BP >210/120, as such UA done
Follow up
- If UA positive or if cannot obtain
- Within 5 days, send to ED
- If UA negative and can obtain
- In 5 days and resume BP meds
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Hypertensive Retinopathy, OU Systemic and consult topics - Clinical checklist
Follow up
- PCP 1 week for HTN management
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Interstitial Keratitis Systemic and consult topics - Clinical checklist
Past ocular history
Key history
- Past ocular history
- No hearing loss or tinnitus
- Deep corneal haze or scarring
- Corneal stromal blood vessels containing minimal or no blood (ghost vessels)
- Frontal bossing (syphilis)
- Hypopigmented or anesthetic skin lesions and thickened skin folds
- Loss of the temporal eyebrow
Exam findings
- Unclear etiology but chronic appearance
- Likely old herpetic insult
Workup
- Acute Corneal stromal blood vessels
- Fine endothelial keratic precipitates conjunctival injection.Chronic Deep corneal haze or scarring
- Corneal stromal blood vessels containing minimal or no blood (ghost vessels)
- Stromal thinning External No saddle-nose deformity
- Frontal bossing (syphilis)
- Hypopigmented or anesthetic skin lesions and thickened skin folds
- Loss of the temporal eyebrow
Differential
- HSV, VZV, congen syphilism acquired syphilis, TB (unilateral, sectoral), EBV, lyme, leprosy, cogan syndrome (bilateral IK, vertigo, tinnitus, hearing loss), systemic vasculitis
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Myopic Degeneration Systemic and consult topics - Clinical checklist
CVF full- DFE w/ myopic crescent PPA adjacent to the disc
Key history
- CVF full- DFE w/ myopic crescent PPA adjacent to the disc
- Oblique optic disc tilt- Macular pigmentary abnormalities
- Hyperpigmented spots in the macula (Fuchs spots)- No retinal breaks or detachment
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Neuroretinitis Systemic and consult topics - Patient education + clinical checklist
Pending Assessment Optic nerve edema with macular exudate star consistent with neuroretinitis
Key history
- Pending Assessment Optic nerve edema with macular exudate star consistent with neuroretinitis
- There is no retinal vasculitis, multiple arterial macroaneurysms, or peripheral capillary nonperfusion to suggest IRVAN
- There is no vitreous cells, deep gray-white retinal lesions, or nematode to suggest DUSN
- Erythromycin (discuss dosing with pharmacy)
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Orbital Compartment Syndrome Systemic and consult topics - Clinical checklist
From traumatic retrobulbar hemorrhage, Mechanism: Recent trauma- Pain, decreased vision, unable to open eyelids
Key history
- From traumatic retrobulbar hemorrhage, Mechanism: Recent trauma- Pain, decreased vision, unable to open eyelids
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Ocular Ischemic Syndrome/Carotid Occlusive Disease Systemic and consult topics - Clinical checklist
Visual loss, transient visual loss, amaurosis fugax, ocular pain, carotid disease, smoking, diabetes, hypertension, hyperlipidemia, or prior stroke/TIA raise concern for ocular hypoperfusion.
Key history
- Visual loss, transient visual loss, amaurosis fugax, ocular pain, carotid disease, smoking, diabetes, hypertension, hyperlipidemia, or prior stroke/TIA raise concern for ocular hypoperfusion.
Workup
- Carotid duplex ultrasound is commonly first-line; CTA or MRA can further define surgically significant or equivocal carotid disease.
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Phthisis bulbi, Blind Painful Eye Systemic and consult topics - Clinical checklist
Phthisical eyes may be soft, shrunken, disorganized, scarred, opaque, thickened, or cosmetically altered; exclude treatable inflammation, infection, malignancy, and pressure-related pain.
Exam findings
- Phthisical eyes may be soft, shrunken, disorganized, scarred, opaque, thickened, or cosmetically altered; exclude treatable inflammation, infection, malignancy, and pressure-related pain.
Management
- Primary goal is comfort and cosmesis, starting with medical pain control when appropriate and escalating to cyclodestructive, injection, evisceration, or enucleation discussions when pain persists.
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Punctate Inner Choroidopathy Systemic and consult topics - Clinical checklist
(PIC), Blurred vision, paracentral scotoma, and/or photopsias, usually in young myopic women, bilateral- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
Key history
- (PIC), Blurred vision, paracentral scotoma, and/or photopsias, usually in young myopic women, bilateral- Denies history of multiple sexual partners, HIV/AIDs, cancer, immunosuppression, Tb exposure
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Pingueculitis Systemic and consult topics - Patient education
You were diagnosed with pingueculitis, which is inflammation on the front of the eye- A pinguecula is a small area of your conjunctiva (the transparent tissue overlying the white part of your eye) that has some disorganized collagen
Key history
- You were diagnosed with pingueculitis, which is inflammation on the front of the eye- A pinguecula is a small area of your conjunctiva (the transparent tissue overlying the white part of your eye) that has some disorganized collagen
- These are very common and many people have them
- Usually pinguecula do not cause any issues but sometimes they can cause some irritation as in your case
Follow up
- In 2 weeks in eye clinic
- It is important that we check your eye pressure at this visit because the ointment we are prescribing can sometimes raise your eye pressure
- If you have any new changes to your vision including persistent flashes of light, numerous new floaters, a curtain across the vision, pain with eye movement, double vision, or worsening blurry vision
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Purtscher Retinopathy Systemic and consult topics - Clinical checklist
History of compression injury to the head, chest, or lower extremities No history of Purtscher
Key history
- History of compression injury to the head, chest, or lower extremities No history of Purtscher
Exam findings
- No clear etiology, will monitor outpatient for resolution over weeks to months and
Workup
- C3/C4, T
Management
- Repeat dilated fundus examination in 2 to 4 weeks in retina- Patient to follow with PCP 1 week to review outstanding blood work and complete systemic workup to investigate other causes
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Retinoschisis Systemic and consult topics - Clinical checklist
Degenerative retinoschisis is often asymptomatic; ask about flashes, floaters, field defect, family history, and symptoms suggesting retinal detachment.
Key history
- Degenerative retinoschisis is often asymptomatic; ask about flashes, floaters, field defect, family history, and symptoms suggesting retinal detachment.
Exam findings
- Smooth dome-shaped peripheral retinal splitting, commonly inferotemporal, with an absolute scotoma supports degenerative retinoschisis.
- Differentiate schisis cavity from rhegmatogenous retinal detachment and note inner or outer wall breaks.
Management
- Most degenerative retinoschisis is observed because progression is uncommon; treatment is reserved for selected progressive schisis detachment or retinal detachment scenarios.
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Staph Marginal Keratitis Systemic and consult topics - Clinical checklist
Pain, foreign-body sensation, photophobia, injection, recurrent episodes, and blepharitis symptoms support staphylococcal marginal keratitis.
Key history
- Pain, foreign-body sensation, photophobia, injection, recurrent episodes, and blepharitis symptoms support staphylococcal marginal keratitis.
Exam findings
- Peripheral stromal infiltrates parallel to the limbus with a clear zone of intervening cornea are typical.
- Epithelial defect or ulceration requires care to distinguish sterile marginal disease from infectious keratitis.
Management
- Control eyelid bacterial antigen burden with lid hygiene and blepharitis management.
- Topical anti-inflammatory therapy may be used when infection is not suspected; epithelial defects often require antibiotic coverage and close monitoring.
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Subperiosteal Abscess Systemic and consult topics - Clinical checklist
Management
- Additional imaging, exploration, and drainage may be indicated if improvement does not occur rapidly.- Do not reimage immediately unless the patient is deteriorating postoperatively
- Imaging usually lags behind clinical response by at least 48 to 72 hours
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Systemic Fungemia without evidence of ocular involvement Systemic and consult topics - Clinical checklist
Management
- AAO recommendations do not support routine ophthalmology screening for candidemia without ocular symptoms; consult remains appropriate for visual symptoms, eye pain, floaters, or concern for ocular infection.
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Thyroid Eye Disease Systemic and consult topics - Patient education + clinical checklist
Early: Nonspecific complaints including foreign-body sensation, redness, tearing, photophobia, and morning puffiness of the eyelids
Key history
- Early: Nonspecific complaints including foreign-body sensation, redness, tearing, photophobia, and morning puffiness of the eyelids
- Additional eyelid and orbital symptoms including lateral flare
- Persistent eyelid swelling
- "pressure" behind the eyes
- Decreased vision.- ROS negative for a rapid pulse
- Hot and dry skin
- Diffusely enlarged thyroid gland (goiter)
Exam findings
- VA stable, CP 8/8 OU, EOM full, denies diplopia
Workup
- Most cases of unilateral proptosis or any bilateral proptosis without upper eyelid retraction)
- TSH receptor antibody- Serum vitamin D level
Follow up
- In cases of severe visual loss, admission for pulsed intravenous therapy may be indicated